Provider Demographics
NPI:1902119902
Name:BOGIN, STACI (DPM)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:BOGIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:MCCORVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3879 E 120TH AVE
Mailing Address - Street 2:#337
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-1658
Mailing Address - Country:US
Mailing Address - Phone:720-328-2022
Mailing Address - Fax:720-328-1224
Practice Address - Street 1:3655 E 104TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-4469
Practice Address - Country:US
Practice Address - Phone:720-328-2022
Practice Address - Fax:720-328-1224
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD-698213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPOD-698OtherCOLORADO PODIATRY LICENSE