Provider Demographics
NPI:1497745830
Name:BOGLE, SHAWN D (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:D
Last Name:BOGLE
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 1:414 W OLD MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72687-8284
Mailing Address - Country:US
Mailing Address - Phone:870-449-4221
Mailing Address - Fax:870-449-6777
Practice Address - Street 1:414 W OLD MAIN ST
Practice Address - Street 2:
Practice Address - City:YELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72687-8284
Practice Address - Country:US
Practice Address - Phone:870-449-4221
Practice Address - Fax:870-449-6777
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146282001Medicaid
AR146282001Medicaid
AR5M073Medicare PIN