Provider Demographics
NPI:1457562050
Name:OGANESOV, RUBEN (MD)
Entity Type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:
Last Name:OGANESOV
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 1:39 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-2301
Mailing Address - Country:US
Mailing Address - Phone:617-783-5783
Mailing Address - Fax:617-783-1519
Practice Address - Street 1:39 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-2301
Practice Address - Country:US
Practice Address - Phone:617-783-5783
Practice Address - Fax:617-783-1519
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56569208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3057291Medicaid
MA9762736Medicaid
MAL-6700Medicare ID - Type UnspecifiedGROUP
MAJ09295Medicare ID - Type UnspecifiedPERSONAL