Provider Demographics
NPI:1639125115
Name:HOGUE, GRADY C JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:C
Last Name:HOGUE
Suffix:JR
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 1:2900 E 29TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2623
Mailing Address - Country:US
Mailing Address - Phone:979-436-0503
Mailing Address - Fax:979-776-6905
Practice Address - Street 1:2900 E 29TH ST STE 200
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2623
Practice Address - Country:US
Practice Address - Phone:979-776-8440
Practice Address - Fax:979-776-6905
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8HG239OtherBCBS
TXAETNAOtherINDIVIDUAL ID NUMBER
TX136310314Medicaid
TX136310310Medicaid
8HG239OtherBCBS
TXC17012Medicare UPIN
TX136310310Medicaid