Provider Demographics
NPI:1295974368
Name:HOGAN, WILLIAM E (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:E
Last Name:HOGAN
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 1:651 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4071
Mailing Address - Country:US
Mailing Address - Phone:208-239-2110
Mailing Address - Fax:
Practice Address - Street 1:651 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4071
Practice Address - Country:US
Practice Address - Phone:208-239-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003746700Medicaid