Healthcare Provider Details

I. General information

NPI: 1851824379
Provider Name (Legal Business Name): KSENIA MARY ROGALO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KSENIA VONGVIPHUT D.O.

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 FRONTAGE RD OFC 114
HAMPTON NJ
08827-4031
US

IV. Provider business mailing address

109 W 27TH ST RM 5S
NEW YORK NY
10001-6208
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax:
Mailing address:
  • Phone: 833-351-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02009271A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MB13051300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A25622
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number345676
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: