Provider Demographics
NPI:1437347317
Name:BUGAEFF, LEO BORISOVICH I (IDC/RN)
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:BORISOVICH
Last Name:BUGAEFF
Suffix:I
Gender:M
Credentials:IDC/RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4643 DOCK RD BLDG 524
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93043-4321
Mailing Address - Country:US
Mailing Address - Phone:805-982-2464
Mailing Address - Fax:
Practice Address - Street 1:4643 DOCK RD BLDG 524
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4378
Practice Address - Country:US
Practice Address - Phone:805-982-2464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman