Provider Demographics
NPI:1649233073
Name:BOGROV, MOIRA U (MD)
Entity Type:Individual
Prefix:DR
First Name:MOIRA
Middle Name:U
Last Name:BOGROV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:DEPT OF CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:DEPT OF PSYCHIATRY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-5355
Practice Address - Fax:410-601-6302
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00371212084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD093591300Medicaid
MDS582I782Medicare PIN