Healthcare Provider Details

I. General information

NPI: 1669567962
Provider Name (Legal Business Name): JOHN C BOGUE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 VILLAGE PLAZA WAY
N. SCITUATE RI
02857
US

IV. Provider business mailing address

19 VILLAGE PLAZA WAY
N. SCITUATE RI
02857
US

V. Phone/Fax

Practice location:
  • Phone: 401-934-2600
  • Fax: 401-934-3563
Mailing address:
  • Phone: 401-934-2600
  • Fax: 401-934-3563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number000292
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: