Provider Demographics
NPI:1487629556
Name:BOGGS, BRIAN R (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:BOGGS
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 1:4401 W MEMORIAL RD
Mailing Address - Street 2:140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:SUITE 610
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-749-7023
Practice Address - Fax:405-749-7024
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK139552086X0206X, 208G00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100124430AMedicaid
OK$$$$$$$$$004OtherBCBS
OKB74468Medicare UPIN
OK$$$$$$$$$004OtherBCBS
OK248510822Medicare PIN