Provider Demographics
NPI:1558444794
Name:BOGGESS, BLAKE REID (DO)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:REID
Last Name:BOGGESS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DUKE UNIVERSITY MEDICAL CTR
Mailing Address - Street 2:DUMC 3886
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DUKE UNIVERSITY MEDICAL CTR
Practice Address - Street 2:DUMC 3886
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-681-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-00496207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2401906Medicare ID - Type Unspecified
I08518Medicare ID - Type Unspecified
NC891360JMedicare ID - Type Unspecified