Provider Demographics
NPI:1245211556
Name:BOGUE, CLIFFORD W (MD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:W
Last Name:BOGUE
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:PO BOX 9805
Mailing Address - Street 2:300 GEORGE STREET 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:203-785-7998
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YALE-NEW HAVEN CHILDREN'S HOSPITAL-WP
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-4651
Practice Address - Fax:203-737-2786
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0316572080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001316571Medicaid
CT001316571Medicaid
CT370000684Medicare ID - Type Unspecified