Provider Demographics
NPI:1922218403
Name:BOGGARAM, BHAGYALAKSHMI GOPAL (MD)
Entity Type:Individual
Prefix:DR
First Name:BHAGYALAKSHMI
Middle Name:GOPAL
Last Name:BOGGARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BHAGYA
Other - Middle Name:G
Other - Last Name:BOGGARAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:4061 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2611
Practice Address - Country:US
Practice Address - Phone:630-961-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN35082084N0400X
IL036-1672142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204805001Medicaid
TX8L18059Medicare PIN
TX301024YWKPMedicare PIN
TXP00834557Medicare PIN
TX204805001Medicaid