Healthcare Provider Details

I. General information

NPI: 1861438004
Provider Name (Legal Business Name): THOMAS PAUL BOGAARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/07/2023
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S GRAND AVE
LOS ANGELES CA
90015-3010
US

IV. Provider business mailing address

PO BOX 1004
SIERRA MADRE CA
91025-4004
US

V. Phone/Fax

Practice location:
  • Phone: 213-802-0100
  • Fax: 626-795-3229
Mailing address:
  • Phone: 818-378-1025
  • Fax: 626-795-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG21222
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG21222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: