Healthcare Provider Details

I. General information

NPI: 1851438329
Provider Name (Legal Business Name): GARY N BOGART D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 CAMPUS POINT DRIVE LLB MAIL CODE - 0968
LA JOLLA CA
92037-0968
US

IV. Provider business mailing address

9350 CAMPUS POINT DRIVE LLB MAIL CODE - 0968
LA JOLLA CA
92037-0968
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-8600
  • Fax: 858-657-8587
Mailing address:
  • Phone: 858-657-8600
  • Fax: 858-657-8587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A6243
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: