Provider Demographics
NPI:1922025808
Name:BOGE, LAURIE ALLISON (DO)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ALLISON
Last Name:BOGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:BOYD
Other - Last Name:PEMBERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3080 INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133
Mailing Address - Country:US
Mailing Address - Phone:254-702-8210
Mailing Address - Fax:724-430-3098
Practice Address - Street 1:3663 S MIAMI AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133
Practice Address - Country:US
Practice Address - Phone:305-285-2172
Practice Address - Fax:724-430-3098
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013725207P00000X
FLOS10258207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOS013725OtherLICENSE NUMBER