Provider Demographics
NPI:1659781599
Name:BOGOMAZOVA, VERONICA (LAC)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:BOGOMAZOVA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 MANOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:908-338-1077
Mailing Address - Fax:
Practice Address - Street 1:740 NJ-34
Practice Address - Street 2:2ND FLOOR, SUITE E
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-6688
Practice Address - Country:US
Practice Address - Phone:732-540-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00101400171100000X
NY005083171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MZ00101400OtherNJ STATE ACUPUNCTURE LICENSE