Provider Demographics
NPI:1063984326
Name:POGUE, JOHN DAVIS III
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVIS
Last Name:POGUE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 AIRPORT RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4159
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:
Practice Address - Street 1:503 AIRPORT RD STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4159
Practice Address - Country:US
Practice Address - Phone:541-858-8170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator