MEDICARE: HENRY G BOGEN OD

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	152W00000X	Optometrist	1392	AZ

General Provider Information

NPI Number	:	1396765897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HENRY G BOGEN OD

Provider Business Mailing Address
First Line	:	4723 N LA LOMITA
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-5941
Country	:	US
Telephone Number	:	520-577-4948
Fax Number	:	520-577-4948

Provider Business Practice Location Address
First Line	:	2250 EL MERCADO LOOP
Second Line	:
City	:	SIERRA VISTA
State	:	AZ
Zip	:	85635-5204
Country	:	US
Telephone Number	:	520-452-8911
Fax Number	:

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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