Basic Information
| Provider Information | |||||||||
| NPI: | 1447210208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOGAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 GRAHAM DR | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773756408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815166530 | ||||||||
| FaxNumber: | 2812909824 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 GRAHAM DR | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773756408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815166530 | ||||||||
| FaxNumber: | 2812909824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | L6064 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 158925101 | 05 | TX | MEDICAID |