Provider Demographics
NPI:1699782359
Name:BOGEL, MARK WW (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WW
Last Name:BOGEL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:2601 CENTENNIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3087
Practice Address - Country:US
Practice Address - Phone:651-777-7414
Practice Address - Fax:651-748-5839
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-04-16
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Provider Licenses
StateLicense IDTaxonomies
MN40645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN059723600Medicaid
MN059723600Medicaid