Provider Demographics
NPI:1396765897
Name:BOGEN, HENRY G (OD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:G
Last Name:BOGEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4723 N LA LOMITA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5941
Mailing Address - Country:US
Mailing Address - Phone:520-577-4948
Mailing Address - Fax:520-577-4948
Practice Address - Street 1:2250 EL MERCADO LOOP
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-5204
Practice Address - Country:US
Practice Address - Phone:520-452-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1392152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U76730Medicare UPIN