Healthcare Provider Details

I. General information

NPI: 1316174873
Provider Name (Legal Business Name): BENJAMIN A BOGRAD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 DAN PROCTOR DR STE 240
SAINT MARYS GA
31558-3801
US

IV. Provider business mailing address

2040 DAN PROCTOR DR STE 240
SAINT MARYS GA
31558-3801
US

V. Phone/Fax

Practice location:
  • Phone: 912-576-6340
  • Fax: 912-576-6341
Mailing address:
  • Phone: 912-576-6340
  • Fax: 912-576-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0102202765
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number84722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: