MEDICARE: GARY BOGGUS MD, PC

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	174400000X	Specialist	0101050420	VA

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	:	1972956944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARY BOGGUS MD, PC

Provider Business Mailing Address
First Line	:	6353 CENTER DR
Second Line	:	SUITE 204
City	:	NORFOLK
State	:	VA
Zip	:	23502-4112
Country	:	US
Telephone Number	:	757-461-3313
Fax Number	:	757-461-8363

Provider Business Practice Location Address
First Line	:	6353 CENTER DR
Second Line	:	SUITE 204
City	:	NORFOLK
State	:	VA
Zip	:	23502-4112
Country	:	US
Telephone Number	:	757-461-3313
Fax Number	:	757-461-8363

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. STEPHANIE P HARPER
Credential	:
Telephone Number	:	757-461-3313

Provider Enumeration Date	:	07/14/2016
Last Update Date	:	07/14/2016

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