Healthcare Provider Details

I. General information

NPI: 1649288663
Provider Name (Legal Business Name): MARY MICHELLE BOGEN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 THE RIALTO
VENICE FL
34285-3524
US

IV. Provider business mailing address

712 THE RIALTO
VENICE FL
34285-3524
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-0222
  • Fax: 941-480-1668
Mailing address:
  • Phone: 941-488-0222
  • Fax: 941-480-1668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO3104
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: