Provider Demographics
NPI:1407968621
Name:BOGDANOVECZ, BRENT MICHAEL (DC)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:MICHAEL
Last Name:BOGDANOVECZ
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 1:317 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717
Mailing Address - Country:US
Mailing Address - Phone:580-327-0032
Mailing Address - Fax:580-327-0330
Practice Address - Street 1:317 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717
Practice Address - Country:US
Practice Address - Phone:580-327-0032
Practice Address - Fax:580-327-0330
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5099U1706Medicare ID - Type Unspecified