Provider Demographics
NPI:1376688127
Name:BOGAN, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:BOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 CAPITAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-5015
Mailing Address - Country:US
Mailing Address - Phone:269-962-9515
Mailing Address - Fax:269-969-6008
Practice Address - Street 1:713 CAPITAL AVE SW
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-5015
Practice Address - Country:US
Practice Address - Phone:269-962-9515
Practice Address - Fax:269-969-6008
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIWB043185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1101304942OtherBCBS #
MI382527315050OtherCOMMUNITY CHOICE #
MI382527315050OtherCOMMUNITY CHOICE #
MI0130494Medicare ID - Type Unspecified