Provider Demographics
NPI:1245210111
Name:BOGHOSSIAN, STEPHEN P (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:P
Last Name:BOGHOSSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1200 S YORK RD
Mailing Address - Street 2:SUITE 4240
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5626
Mailing Address - Country:US
Mailing Address - Phone:630-834-7590
Mailing Address - Fax:630-516-9123
Practice Address - Street 1:1200 S YORK RD
Practice Address - Street 2:SUITE 4240
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5626
Practice Address - Country:US
Practice Address - Phone:630-834-7590
Practice Address - Fax:630-516-9123
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL585990Medicare ID - Type Unspecified
ILG15247Medicare UPIN