Provider Demographics
NPI:1306827779
Name:BOGART, PETER ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ALLEN
Last Name:BOGART
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BOW ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-4807
Mailing Address - Country:US
Mailing Address - Phone:781-891-9734
Mailing Address - Fax:781-647-7940
Practice Address - Street 1:6 BOW ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-4807
Practice Address - Country:US
Practice Address - Phone:781-891-9734
Practice Address - Fax:781-647-7940
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA671111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1601539Medicaid
T58197Medicare UPIN
MAY35479Medicare ID - Type Unspecified