Provider Demographics
NPI:1942659016
Name:BOGENBERGER, KENNETH JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:BOGENBERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:818-669-0403
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-580-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
HIMD19764208600000X
CAA1764422086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN