Provider Demographics
NPI:1881629103
Name:BOGDAN, MICHAEL A (MD, FACS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BOGDAN
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N CARROLL AVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6455
Mailing Address - Country:US
Mailing Address - Phone:817-442-1236
Mailing Address - Fax:817-442-1247
Practice Address - Street 1:410 N CARROLL AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6455
Practice Address - Country:US
Practice Address - Phone:817-442-1236
Practice Address - Fax:817-442-1247
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM6055208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A692800Medicare ID - Type Unspecified
CAI44355Medicare UPIN