Provider Demographics
NPI:1871676502
Name:BOUZAGLOU, SANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:BOUZAGLOU
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 1:501 DARBY CREEK RD
Mailing Address - Street 2:SUITE 59
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1604
Mailing Address - Country:US
Mailing Address - Phone:859-263-8083
Mailing Address - Fax:859-263-9160
Practice Address - Street 1:501 DARBY CREEK RD
Practice Address - Street 2:SUITE 59
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1604
Practice Address - Country:US
Practice Address - Phone:859-263-8083
Practice Address - Fax:859-263-9160
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25984174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0877901Medicare ID - Type Unspecified
KYE87673Medicare UPIN