Provider Demographics
NPI:1316187776
Name:BOGART, COURTNEY LAURA (DPM)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:LAURA
Last Name:BOGART
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 W SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1259
Mailing Address - Country:US
Mailing Address - Phone:315-331-5059
Mailing Address - Fax:
Practice Address - Street 1:165 W SHORE BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1259
Practice Address - Country:US
Practice Address - Phone:315-331-5059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY65 006366213E00000X
RILPR00075213E00000X
MALIMITED LICENSE 1200213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist