Provider Demographics
NPI:1831335702
Name:MICHAEL A. BOGDAN, MD, PLLC
Entity type:Organization
Organization Name:MICHAEL A. BOGDAN, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:BOGDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-442-1236
Mailing Address - Street 1:410 N CARROLL AVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6455
Mailing Address - Country:US
Mailing Address - Phone:817-442-1236
Mailing Address - Fax:817-442-1247
Practice Address - Street 1:410 N CARROLL AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6455
Practice Address - Country:US
Practice Address - Phone:817-442-1236
Practice Address - Fax:817-442-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-26
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6055208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty