Healthcare Provider Details

I. General information

NPI: 1790711059
Provider Name (Legal Business Name): SONDRA IACULLO BOGURSKY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 SCOVILL ST 3RD FLOOR
WATERBURY CT
06706-1113
US

IV. Provider business mailing address

56 FRANKLIN ST 3RD FLOOR
WATERBURY CT
06706-1221
US

V. Phone/Fax

Practice location:
  • Phone: 203-709-3800
  • Fax: 203-709-3869
Mailing address:
  • Phone: 203-709-8873
  • Fax: 203-709-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042480
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042480
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: