Healthcare Provider Details

I. General information

NPI: 1336140896
Provider Name (Legal Business Name): DONALD E BOGARD II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 MIAMI VALLEY DR STE 500
CENTERVILLE OH
45459-4780
US

IV. Provider business mailing address

6680 POE AVE SUITE 200
DAYTON OH
45414-2854
US

V. Phone/Fax

Practice location:
  • Phone: 937-425-0003
  • Fax: 937-245-6308
Mailing address:
  • Phone: 937-280-8400
  • Fax: 937-280-8373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50-00-0768
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50-000768
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: