Provider Demographics
NPI:1851414031
Name:BOUGAKOV, DMITRI (PHD)
Entity Type:Individual
Prefix:
First Name:DMITRI
Middle Name:
Last Name:BOUGAKOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W 57TH ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3158
Mailing Address - Country:US
Mailing Address - Phone:646-496-8963
Mailing Address - Fax:
Practice Address - Street 1:315 W 57TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3158
Practice Address - Country:US
Practice Address - Phone:646-496-8963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 017107103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02969217Medicaid
NYVN4541Medicare PIN