Provider Demographics
NPI:1043228349
Name:MAMIKOGLU, BULENT (MD)
Entity Type:Individual
Prefix:DR
First Name:BULENT
Middle Name:
Last Name:MAMIKOGLU
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 1:4495 MIDDLE CHESHIRE RD
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-8327
Mailing Address - Country:US
Mailing Address - Phone:815-993-4266
Mailing Address - Fax:
Practice Address - Street 1:1 WEBSTER AVE STE 307
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1365
Practice Address - Country:US
Practice Address - Phone:914-693-7636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3010207KA0200X, 207Y00000X
IL036117864207Y00000X
NY303313207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117864-1Medicaid
AR145362001Medicaid
AR5M030OtherBLUE CROSS