Healthcare Provider Details

I. General information

NPI: 1730823105
Provider Name (Legal Business Name): JACK JEROME VOGEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 S LYNCREST PL
SIOUX FALLS SD
57108-2565
US

IV. Provider business mailing address

6900 S LYNCREST PL
SIOUX FALLS SD
57108-2565
US

V. Phone/Fax

Practice location:
  • Phone: 605-338-7098
  • Fax: 605-322-8885
Mailing address:
  • Phone: 605-338-7098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0116036983
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: