Healthcare Provider Details

I. General information

NPI: 1740356088
Provider Name (Legal Business Name): DEVIN L BOGUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2468
US

IV. Provider business mailing address

9201 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2468
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-2505
  • Fax: 505-298-2985
Mailing address:
  • Phone: 505-298-2505
  • Fax: 505-298-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2013-0041
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: