Provider Demographics
NPI:1841290723
Name:BOGDANOV, ASSEN PETROV (MD)
Entity type:Individual
Prefix:
First Name:ASSEN
Middle Name:PETROV
Last Name:BOGDANOV
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 1:3 BARKER AVE 4
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-1524
Mailing Address - Country:US
Mailing Address - Phone:914-949-1199
Mailing Address - Fax:914-949-1245
Practice Address - Street 1:69 S BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-4004
Practice Address - Country:US
Practice Address - Phone:914-376-5555
Practice Address - Fax:914-964-1477
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA12165500207R00000X
NY228483207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02463867Medicaid
NY02463867Medicaid
NY186AE1Medicare ID - Type Unspecified