Provider Demographics
NPI:1598090490
Name:BOGNER, KENNETH G
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:BOGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 MCWILLIAMS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257
Mailing Address - Country:US
Mailing Address - Phone:210-295-8336
Mailing Address - Fax:
Practice Address - Street 1:5425 MCWILLIAMS
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257
Practice Address - Country:US
Practice Address - Phone:210-295-8336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians