Provider Demographics
NPI:1184057077
Name:VOGEL, MICHAEL SHANE (IDC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHANE
Last Name:VOGEL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 HOLLIS LAKES RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-9316
Mailing Address - Country:US
Mailing Address - Phone:803-487-8004
Mailing Address - Fax:
Practice Address - Street 1:2480 BON HOMMES RICHARD STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32227
Practice Address - Country:US
Practice Address - Phone:803-579-0540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman