Healthcare Provider Details

I. General information

NPI: 1265429617
Provider Name (Legal Business Name): JOHN R. BOGDASARIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 ELECTRIC AVE
FITCHBURG MA
01420-7954
US

IV. Provider business mailing address

33 ELECTRIC AVENUE SUITE 202
FITCHBURG MA
01420
US

V. Phone/Fax

Practice location:
  • Phone: 978-342-1200
  • Fax: 978-345-8014
Mailing address:
  • Phone: 978-342-1200
  • Fax: 978-345-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number33995
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: