Provider Demographics
NPI:1942258967
Name:HOGGE, MARK WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:HOGGE
Suffix:
Gender:M
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:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14702-0788
Mailing Address - Country:US
Mailing Address - Phone:214-926-8614
Mailing Address - Fax:716-664-9160
Practice Address - Street 1:796 FAIRMOUNT AVE # WE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2547
Practice Address - Country:US
Practice Address - Phone:716-664-9731
Practice Address - Fax:716-664-9160
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ14612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128608002Medicaid
TX80078RMedicare ID - Type Unspecified
TX128608002Medicaid