Provider Demographics
NPI:1649288663
Name:BOGEN, MARY MICHELLE (DPM)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:MICHELLE
Last Name:BOGEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 THE RIALTO
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3524
Mailing Address - Country:US
Mailing Address - Phone:941-488-0222
Mailing Address - Fax:941-480-1668
Practice Address - Street 1:712 THE RIALTO
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3524
Practice Address - Country:US
Practice Address - Phone:941-488-0222
Practice Address - Fax:941-480-1668
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3104213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1808AOtherRAILROAD MEDICARE
FLU1808Medicare PIN
U97657Medicare UPIN
FLU1808AMedicare PIN