Provider Demographics
NPI:1427508076
Name:BOGDA, MITCHELL (CST)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:BOGDA
Suffix:
Gender:M
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 BERTRAM DR UNIT K
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-3212
Mailing Address - Country:US
Mailing Address - Phone:630-418-8008
Mailing Address - Fax:
Practice Address - Street 1:132 BERTRAM DR UNIT K
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-3212
Practice Address - Country:US
Practice Address - Phone:630-418-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL157219246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist