Healthcare Provider Details

I. General information

NPI: 1487629556
Provider Name (Legal Business Name): BRIAN R BOGGS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W MEMORIAL RD SUITE 610
OKLAHOMA CITY OK
73120-9350
US

IV. Provider business mailing address

4401 W MEMORIAL RD 140
OKLAHOMA CITY OK
73134-1785
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-7023
  • Fax: 405-749-7024
Mailing address:
  • Phone: 405-752-3162
  • Fax: 405-936-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number13955
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number13955
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number13955
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: