Provider Demographics
NPI:1740417476
Name:BOGLE, MISTY MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MARIE
Last Name:BOGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-5803
Mailing Address - Country:US
Mailing Address - Phone:405-201-3381
Mailing Address - Fax:
Practice Address - Street 1:608 NW 9TH ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1068
Practice Address - Country:US
Practice Address - Phone:405-231-3000
Practice Address - Fax:405-231-3073
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-21
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine