Healthcare Provider Details

I. General information

NPI: 1588046585
Provider Name (Legal Business Name): THEODORE OGREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

77 NEALY AVE
HAMPTON VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8600
  • Fax:
Mailing address:
  • Phone: 757-225-7360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101266263
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: