Healthcare Provider Details

I. General information

NPI: 1003085630
Provider Name (Legal Business Name): PETER SHELBY BOGARD DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SW RAMSEY SUITE 104
GRANTS PASS OR
97527-5788
US

IV. Provider business mailing address

700 SW RAMSEY SUITE 104
GRANTS PASS OR
97527-5788
US

V. Phone/Fax

Practice location:
  • Phone: 541-471-4930
  • Fax: 541-471-1331
Mailing address:
  • Phone: 541-471-4930
  • Fax: 541-471-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDO18557
License Number StateOR

VIII. Authorized Official

Name: DR. PETER SHELBY BOGARD
Title or Position: DOCTOR
Credential: D.O.
Phone: 541-471-4930