Healthcare Provider Details

I. General information

NPI: 1578555876
Provider Name (Legal Business Name): DANA JUNE HOGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 CAPITAL AVE STE 105
WATKINSVILLE GA
30677-1832
US

IV. Provider business mailing address

1160 CAPITAL AVE STE 105 P O BOX 1379
WATKINSVILLE GA
30677-1832
US

V. Phone/Fax

Practice location:
  • Phone: 706-769-9410
  • Fax: 706-769-9475
Mailing address:
  • Phone: 706-769-9410
  • Fax: 706-769-9475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number044236
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: