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General NPI Number Information
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NPI Number | 1679082010
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Entity Type | Individual
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Provider Name | JACOB BOGART
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Gender | Male
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Dates
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Enumeration Date | 09/28/2017
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Last Update Date | 09/28/2017
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Provider Practice Location Address
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Address Line | 1000 N 92ND ST
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City | MILWAUKEE
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State | WI
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Zip | 53226-3533
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Country | US
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Telephone | 414-721-8065
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Fax |
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Provider Business Mailing Address
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Address Line | 5785 MURRAY ST
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City | NEW BERLIN
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State | WI
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Zip | 53151-8747
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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