Provider Demographics
NPI:1669867776
Name:OGURICK, AMY G
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:G
Last Name:OGURICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LORRAINE
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:380 MATHER ST., BUILDING 4 APT 4407
Mailing Address - Street 2:APT 4407
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514
Mailing Address - Country:US
Mailing Address - Phone:262-853-3334
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program