Provider Demographics
NPI:1689606451
Name:OGLE, BRENT BURTON (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:BURTON
Last Name:OGLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:206 S MULBERRY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3331
Mailing Address - Country:US
Mailing Address - Phone:740-397-3553
Mailing Address - Fax:740-392-4158
Practice Address - Street 1:206 S MULBERRY ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3331
Practice Address - Country:US
Practice Address - Phone:740-397-3553
Practice Address - Fax:740-392-4158
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7301-0207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2267505Medicaid
OH2267505Medicaid
OHH40879Medicare UPIN