=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548527492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ANNE BROGOCH M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2012
-----------------------------------------------------
Last Update Date | 05/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 E ST NW SA-1 SUITE L209, BUREAU OF MEDICAL SERVICES
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-225-0319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 E ST NW SA-1 STE L209 BUREAU OF MEDICAL SERVICES, US DOS
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-225-0319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD172067
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0015X
-----------------------------------------------------
Taxonomy Name | Psychosomatic Medicine Physician
-----------------------------------------------------
License Number | MD500002925
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------