Provider Demographics
NPI:1578617635
Name:BOGAN, MICHAEL LEE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:BOGAN
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 1:10684 GRINDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-7801
Mailing Address - Country:US
Mailing Address - Phone:317-842-7427
Mailing Address - Fax:
Practice Address - Street 1:10684 GRINDSTONE DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7801
Practice Address - Country:US
Practice Address - Phone:317-842-7427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032757A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology