Provider Demographics
NPI:1326650128
Name:B O G ADVANCED FAMILY MEDICAL MANAGEMENT INC
Entity Type:Organization
Organization Name:B O G ADVANCED FAMILY MEDICAL MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:YADIRA
Authorized Official - Last Name:ORTIZ-GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:832-812-9598
Mailing Address - Street 1:20127 IVORY VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-0030
Mailing Address - Country:US
Mailing Address - Phone:832-812-9598
Mailing Address - Fax:
Practice Address - Street 1:20127 IVORY VALLEY LN
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-0030
Practice Address - Country:US
Practice Address - Phone:832-812-9598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP146064OtherINSURANCE