Provider Demographics
NPI:1154556678
Name:BOGATCH, MICHAEL TODD (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:BOGATCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9601 BAPTIST HEALTH DR STE 210
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6342
Practice Address - Country:US
Practice Address - Phone:501-217-3533
Practice Address - Fax:501-217-3578
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA129673207XX0005X
ARE12668207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR237276001Medicaid