Provider Demographics
NPI:1124296967
Name:EUGENE I BOGAGE OPTOMETRY
Entity type:Organization
Organization Name:EUGENE I BOGAGE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOGAGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-385-5446
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:1464 RT 61 SOUTH
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-0749
Mailing Address - Country:US
Mailing Address - Phone:570-385-5446
Mailing Address - Fax:570-385-5517
Practice Address - Street 1:1464 RT 61 SOUTH
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-0749
Practice Address - Country:US
Practice Address - Phone:570-385-5446
Practice Address - Fax:570-385-5517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0263270001Medicare NSC
PAU07863Medicare UPIN