Healthcare Provider Details

I. General information

NPI: 1912931460
Provider Name (Legal Business Name): JEFFREY A BOGART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EAST GENESEE ST. SUITE 101
SYRACUSE NY
13210
US

IV. Provider business mailing address

1000 EAST GENESEE ST. SUITE 101
SYRACUSE NY
13210
US

V. Phone/Fax

Practice location:
  • Phone: 315-476-3535
  • Fax: 315-476-4140
Mailing address:
  • Phone: 315-476-3535
  • Fax: 315-476-4140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number190748
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: