Healthcare Provider Details

I. General information

NPI: 1053395319
Provider Name (Legal Business Name): JEFFREY MICHAEL HOGAN PT, MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14890 SE 29TH ST
CHOCTAW OK
73020-3515
US

IV. Provider business mailing address

14890 SE 29TH ST
CHOCTAW OK
73020-3515
US

V. Phone/Fax

Practice location:
  • Phone: 405-390-1731
  • Fax: 405-390-1981
Mailing address:
  • Phone: 405-390-1731
  • Fax: 405-390-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3849
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: