Provider Demographics
NPI:1588637888
Name:BOGDASARIAN, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BOGDASARIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 RIVERSIDE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4176
Mailing Address - Country:US
Mailing Address - Phone:607-770-9471
Mailing Address - Fax:607-797-4699
Practice Address - Street 1:161 RIVERSIDE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4176
Practice Address - Country:US
Practice Address - Phone:607-770-9471
Practice Address - Fax:607-797-4699
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118455208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00373042Medicaid
NYB81013Medicare UPIN
NY34528BMedicare ID - Type Unspecified