Provider Demographics
NPI:1790711059
Name:BOGURSKY, SONDRA IACULLO (MD)
Entity Type:Individual
Prefix:
First Name:SONDRA
Middle Name:IACULLO
Last Name:BOGURSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:56 FRANKLIN ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1221
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:95 SCOVILL ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1113
Practice Address - Country:US
Practice Address - Phone:203-709-3800
Practice Address - Fax:203-709-3869
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042480208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT965608OtherUSA
CTPENDINGOtherRAILROAD MEDICARE
CT3689809/7698594OtherAETNA
CT24-70412OtherUHC
CT001424803Medicaid
CT010042480CT01OtherANTHEM BCBS CT
CT246269OtherWELLCARE
CTPENDINGOtherRAILROAD MEDICARE
CT246269OtherWELLCARE