Provider Demographics
NPI:1972956944
Name:GARY BOGGUS MD, PC
Entity Type:Organization
Organization Name:GARY BOGGUS MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-461-3313
Mailing Address - Street 1:6353 CENTER DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4112
Mailing Address - Country:US
Mailing Address - Phone:757-461-3313
Mailing Address - Fax:757-461-8363
Practice Address - Street 1:6353 CENTER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4112
Practice Address - Country:US
Practice Address - Phone:757-461-3313
Practice Address - Fax:757-461-8363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050420174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1932290988Medicaid