Provider Demographics
NPI:1699731935
Name:BOGGESS, JOHN WILSON IV (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILSON
Last Name:BOGGESS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2337 HOMER CLAYTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976
Mailing Address - Country:US
Mailing Address - Phone:256-582-5131
Mailing Address - Fax:256-582-1100
Practice Address - Street 1:2337 HOMER CLAYTON DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2205
Practice Address - Country:US
Practice Address - Phone:256-582-5131
Practice Address - Fax:256-582-1100
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051550006Medicare ID - Type Unspecified
C72002Medicare UPIN