Provider Demographics
NPI:1659374528
Name:BOGARD, PETER (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:BOGARD
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 1:700 RAMSEY AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5788
Mailing Address - Country:US
Mailing Address - Phone:541-471-4930
Mailing Address - Fax:541-471-1331
Practice Address - Street 1:700 RAMSEY AVE
Practice Address - Street 2:STE 104
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5788
Practice Address - Country:US
Practice Address - Phone:541-471-4930
Practice Address - Fax:541-471-1331
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO18557207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR058748Medicaid
OR058748Medicaid
ORR112565Medicare PIN