Provider Demographics
NPI:1104849710
Name:BOGOMILSKY, JODIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:L
Last Name:BOGOMILSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 OAK GROVE AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4432
Mailing Address - Country:US
Mailing Address - Phone:650-325-1511
Mailing Address - Fax:650-617-1079
Practice Address - Street 1:888 OAK GROVE AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4432
Practice Address - Country:US
Practice Address - Phone:650-325-1511
Practice Address - Fax:650-617-1079
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG81488Medicare UPIN