Provider Demographics
NPI:1841359916
Name:BOGANNAM, NICHOLAS S (DC)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:S
Last Name:BOGANNAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 POST RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5723
Mailing Address - Country:US
Mailing Address - Phone:203-259-4731
Mailing Address - Fax:203-259-7319
Practice Address - Street 1:1995 POST RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5723
Practice Address - Country:US
Practice Address - Phone:203-259-4731
Practice Address - Fax:203-259-7319
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT253CT01111N00000X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT253CT01OtherSTATE LICENSE NUMBER
CT06-1066319OtherTAX ID #
CT350000186Medicare PIN
CT06-1066319OtherTAX ID #