Healthcare Provider Details

I. General information

NPI: 1447226337
Provider Name (Legal Business Name): RAYMOND A BOLOGNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WELLNESS WAY STE 300
MILFORD DE
19963-4366
US

IV. Provider business mailing address

640 S STATE ST # MC3055
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 302-503-2460
  • Fax: 302-424-9162
Mailing address:
  • Phone: 302-480-1688
  • Fax: 302-480-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberC1-0025497
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC1-0025497
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: