Provider Demographics
NPI:1477583268
Name:BOGARTZ, LEON JACOB (MD,)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:JACOB
Last Name:BOGARTZ
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 1:2 WOODSTOCK CT
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29928-3385
Mailing Address - Country:US
Mailing Address - Phone:843-842-7875
Mailing Address - Fax:843-842-9545
Practice Address - Street 1:7540 DANNAHER LN
Practice Address - Street 2:STE. 300
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4013
Practice Address - Country:US
Practice Address - Phone:865-362-8524
Practice Address - Fax:865-545-3115
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000006741174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2002856Medicaid
TN3149626Medicare ID - Type Unspecified
TN2002856Medicaid