Provider Demographics
NPI:1811104581
Name:BAKALOV, BOGDAN (MD)
Entity type:Individual
Prefix:
First Name:BOGDAN
Middle Name:
Last Name:BAKALOV
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 1:2113 E 38TH
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4929
Mailing Address - Country:US
Mailing Address - Phone:718-377-2838
Mailing Address - Fax:718-377-5952
Practice Address - Street 1:92-11 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7857
Practice Address - Country:US
Practice Address - Phone:718-651-0300
Practice Address - Fax:718-639-5513
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153329207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00763337Medicaid
NY00763337Medicaid
NY97A332Medicare ID - Type Unspecified