Provider Demographics
NPI:1821092214
Name:BUGGS, MABLENE (MD)
Entity Type:Individual
Prefix:
First Name:MABLENE
Middle Name:
Last Name:BUGGS
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 1:2620 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1838
Mailing Address - Country:US
Mailing Address - Phone:314-534-0043
Mailing Address - Fax:314-909-0330
Practice Address - Street 1:2620 S 13TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1838
Practice Address - Country:US
Practice Address - Phone:314-534-0043
Practice Address - Fax:314-909-0330
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085587207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202943346Medicaid
IL036085587Medicaid
IL06032182OtherBLUE CROSS BLUE SHIELD
IL3932056OtherBLUE SHIELD
MO1821092214Medicaid
IL06032182OtherBLUE CROSS BLUE SHIELD
IL036085587Medicaid
MO202943346Medicaid
IL214881028Medicare PIN
MO029013209Medicare PIN