Provider Demographics
NPI:1720058001
Name:BOGAN, JENNIFER KIM (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KIM
Last Name:BOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN STE 500
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5349
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:11995 SINGLETREE LN STE 500
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5349
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1252902085R0202X
AZ292232085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCS7943OtherGROUP MEDICARE RAILROAD ID & PTAN
AZ300121549OtherMEDICARE RAILROAD
AZZWCBBMOtherGROUP MEDICARE ID
AZ581969Medicaid
H22374Medicare UPIN
AZ1841261989OtherGROUP NPI
AZ005472OtherGROUP MEDICAID ID
AZ1720058001OtherPHYSICIAN INDIVIDUAL NPI
AZZ65476Medicare PIN