Provider Demographics
NPI:1497793186
Name:BOGAR, KRISTINA NICHOLE (DO)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NICHOLE
Last Name:BOGAR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 ACWORTH DUE WEST RD
Mailing Address - Street 2:BLDG 200, SUITE 220
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3335
Mailing Address - Country:US
Mailing Address - Phone:770-456-5941
Mailing Address - Fax:770-456-5942
Practice Address - Street 1:3450 ACWORTH DUE WEST RD
Practice Address - Street 2:BLDG 200, SUITE 220
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3335
Practice Address - Country:US
Practice Address - Phone:770-456-5941
Practice Address - Fax:770-456-5942
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM0667207Q00000X
GA061943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA863007771DMedicaid
TX1795445Medicaid
TX8F1893Medicare PIN
GA863007771DMedicaid
TX00920ZMedicare PIN