Provider Demographics
NPI:1629044862
Name:DOLGOV, L. DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:L.
Middle Name:DOUGLAS
Last Name:DOLGOV
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 1:20 GUEST ST STE 225
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2065
Mailing Address - Country:US
Mailing Address - Phone:617-738-8642
Mailing Address - Fax:617-202-4172
Practice Address - Street 1:20 GUEST ST STE 225
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2065
Practice Address - Country:US
Practice Address - Phone:617-738-8642
Practice Address - Fax:617-202-4172
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA710002081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3082750Medicaid
MA80575OtherHARVARD PILGRIM
MA720652OtherTUFTS HEALTH PLAN
MA2437395OtherAETNA
MAJ10312OtherBLUE CROSS BLUE SHIELD
MA137530OtherCIGNA
MA2916OtherFALLON COMM. HEALTH PLAN
MAE60898Medicare UPIN
MA3082750Medicaid
MA80575OtherHARVARD PILGRIM