Provider Demographics
NPI:1619984374
Name:BOGARDUS, CARL ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ROBERT
Last Name:BOGARDUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 SW 74TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-3928
Mailing Address - Country:US
Mailing Address - Phone:405-681-4500
Mailing Address - Fax:405-681-0038
Practice Address - Street 1:2200 SW 74TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-3928
Practice Address - Country:US
Practice Address - Phone:405-681-4500
Practice Address - Fax:405-681-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1042152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist