Provider Demographics
NPI:1073050902
Name:BLOODOUGH, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BLOODOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 EDGERTON ST
Mailing Address - Street 2:
Mailing Address - City:MINOA
Mailing Address - State:NY
Mailing Address - Zip Code:13116-1510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 EDGERTON ST
Practice Address - Street 2:
Practice Address - City:MINOA
Practice Address - State:NY
Practice Address - Zip Code:13116-1510
Practice Address - Country:US
Practice Address - Phone:315-256-5835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670456121174400000X
NY705761131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist