Provider Demographics
NPI:1992195697
Name:BOGACHKOV, ABRAHAM (MD)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:BOGACHKOV
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 1:1425 N RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2300
Mailing Address - Country:US
Mailing Address - Phone:224-783-8732
Mailing Address - Fax:
Practice Address - Street 1:1425 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2300
Practice Address - Country:US
Practice Address - Phone:224-783-8732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI746372085R0202X
IL036.1496342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992195697Medicaid