Provider Demographics
NPI:1962452730
Name:POGO, GUSTAVE J (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVE
Middle Name:J
Last Name:POGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-5539
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-4970
Practice Address - Fax:516-562-3786
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY161229207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463501Medicaid
NY01463501Medicaid
NY97F891Medicare ID - Type Unspecified