Provider Demographics
NPI:1588334031
Name:BOGAN, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 HIGHWAY 34 STE 24-25
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-1903
Mailing Address - Country:US
Mailing Address - Phone:732-970-7882
Mailing Address - Fax:732-970-7883
Practice Address - Street 1:1212 HIGHWAY 34 STE 24-25
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NJ
Practice Address - Zip Code:07747-1903
Practice Address - Country:US
Practice Address - Phone:732-970-7882
Practice Address - Fax:732-970-7883
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02035600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist