Healthcare Provider Details

I. General information

NPI: 1922866318
Provider Name (Legal Business Name): JACOB BOGOST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 SW 62ND AVE
SOUTH MIAMI FL
33143-4701
US

IV. Provider business mailing address

2534 S KINNICKINNIC AVE STE 202
MILWAUKEE WI
53207-1608
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-7500
  • Fax:
Mailing address:
  • Phone: 608-630-7786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberUO12003
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: