Provider Demographics
NPI:1457415473
Name:HOGAN, LES WAYNE (OT/L)
Entity Type:Individual
Prefix:MR
First Name:LES
Middle Name:WAYNE
Last Name:HOGAN
Suffix:
Gender:M
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 TORO RD
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36344-1459
Mailing Address - Country:US
Mailing Address - Phone:334-588-3842
Mailing Address - Fax:334-588-0514
Practice Address - Street 1:707 BOLL WEEVIL CIRCLE
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330
Practice Address - Country:US
Practice Address - Phone:334-393-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1892171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-29563OtherBLUE CROSS BLUE SHIELD
ALQ37456Medicare UPIN
AL051555623HOGMedicare PIN