Provider Demographics
NPI:1346600798
Name:BOGDAN, ANTHONY (AT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BOGDAN
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 EASTLAWN DR
Mailing Address - Street 2:APT L12
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-5225
Mailing Address - Country:US
Mailing Address - Phone:989-493-6735
Mailing Address - Fax:
Practice Address - Street 1:1811 EASTLAWN DR
Practice Address - Street 2:APT L12
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-5225
Practice Address - Country:US
Practice Address - Phone:989-493-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-27
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2255A2300XMedicaid