MEDICARE: JERRY D. BOGGS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	MD20969	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003890153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY D. BOGGS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1700
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97470-0414
Country	:	US
Telephone Number	:	541-440-5320
Fax Number	:	541-440-5322

Provider Business Practice Location Address
First Line	:	1741 WEST HARVARD AVE
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471-2716
Country	:	US
Telephone Number	:	541-440-5320
Fax Number	:	541-440-5322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	09/10/2015

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