Provider Demographics
NPI:1386819928
Name:BOLUSA-SABUGO, AHGNES UNGOCO (MD)
Entity Type:Individual
Prefix:
First Name:AHGNES
Middle Name:UNGOCO
Last Name:BOLUSA-SABUGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AHGNES
Other - Middle Name:UNGOCO
Other - Last Name:BOLUSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:134 ELON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-2536
Mailing Address - Country:US
Mailing Address - Phone:434-455-2480
Mailing Address - Fax:434-455-2487
Practice Address - Street 1:320 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24504-2306
Practice Address - Country:US
Practice Address - Phone:434-947-5967
Practice Address - Fax:434-455-2487
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266535207Q00000X
VA0101243921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03495012Medicaid
NYA400078730Medicare PIN