Provider Demographics
NPI:1811196454
Name:WATERFIELD-BOGDEN, ABBY MARIE (DO)
Entity Type:Individual
Prefix:MRS
First Name:ABBY
Middle Name:MARIE
Last Name:WATERFIELD-BOGDEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:ABBY
Other - Middle Name:MARIE
Other - Last Name:WATERFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:866-250-6385
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2601
Practice Address - Fax:586-263-2589
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017479207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
12282263OtherCAQH