Provider Demographics
NPI:1669028494
Name:BOGUMIL, MARY EMMA (DC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:EMMA
Last Name:BOGUMIL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 PARKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3868 E ROBINSON RD
Practice Address - Street 2:
Practice Address - City:WEST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2001
Practice Address - Country:US
Practice Address - Phone:716-564-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013248-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor