Provider Demographics
NPI:1396780144
Name:BOGNER, DALLAS (MD)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:BOGNER
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 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-3200
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:1380 TULLAR RD
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4440
Practice Address - Country:US
Practice Address - Phone:920-727-3480
Practice Address - Fax:920-727-3490
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0034837207Q00000X
WI48225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34683800Medicaid
WI001371290Medicare PIN
WI34683800Medicaid