Provider Demographics
NPI:1265429617
Name:BOGDASARIAN, JOHN R (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BOGDASARIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:33 ELECTRIC AVENUE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420
Mailing Address - Country:US
Mailing Address - Phone:978-342-1200
Mailing Address - Fax:978-345-8014
Practice Address - Street 1:33 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-7954
Practice Address - Country:US
Practice Address - Phone:978-342-1200
Practice Address - Fax:978-345-8014
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2017-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA33995207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2064111Medicaid
MA2064111Medicaid
A38284Medicare UPIN