Healthcare Provider Details

I. General information

NPI: 1154556678
Provider Name (Legal Business Name): MICHAEL TODD BOGATCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 BAPTIST HEALTH DR STE 210
LITTLE ROCK AR
72205-6342
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR STE 200
LITTLE ROCK AR
72211-4393
US

V. Phone/Fax

Practice location:
  • Phone: 501-217-3533
  • Fax: 501-217-3578
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA129673
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberE12668
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: