Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 26467 | AZ |
NPI | 1255327169 |
---|---|
Provider Name | Dr. Mark Pogue |
First Address | Scottsdale, AZ 85255-5443 |
Second Address | Scottsdale, AZ 85255-5438 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2005 |
Last Update Date | 13/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U79221 | (02) | AZ |