Provider Demographics
NPI:1265414569
Name:BOGUS, WILLIAM J (OD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:BOGUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2810
Mailing Address - Country:US
Mailing Address - Phone:801-485-1371
Mailing Address - Fax:801-485-0936
Practice Address - Street 1:2319 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2810
Practice Address - Country:US
Practice Address - Phone:801-485-1371
Practice Address - Fax:801-485-0936
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1106879934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000009685Medicare PIN
UT0626390001Medicare NSC
UTT78163Medicare UPIN