Provider Demographics
NPI:1932290988
Name:BOGGUS, GARY WALKER (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WALKER
Last Name:BOGGUS
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 1:6353 CENTER DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4112
Mailing Address - Country:US
Mailing Address - Phone:757-461-3313
Mailing Address - Fax:757-461-8363
Practice Address - Street 1:6353 CENTER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4112
Practice Address - Country:US
Practice Address - Phone:757-461-3313
Practice Address - Fax:757-461-8363
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010504202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAO84416OtherSENTARA/OPTIMA
VA189521OtherANTHEM BCBS
VA007115920Medicaid
VA189521OtherANTHEM HEALTHKEEPERS
VAG38611Medicare UPIN
VA260002972Medicare ID - Type Unspecified