Provider Demographics
NPI:1114412939
Name:BOGARD, MICHAEL STEPHEN (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:BOGARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13061
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92039-3061
Mailing Address - Country:US
Mailing Address - Phone:714-465-7064
Mailing Address - Fax:858-524-7005
Practice Address - Street 1:8929 UNIVERSITY CENTER LN STE 206
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1008
Practice Address - Country:US
Practice Address - Phone:858-524-7000
Practice Address - Fax:858-524-7005
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17716207XX0005X
MO2023012297207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1114412939Medicaid