Healthcare Provider Details

I. General information

NPI: 1992962088
Provider Name (Legal Business Name): LORIETA H BOGDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2008
Last Update Date: 05/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 1ST AVE
SPRING LAKE NJ
07762-1649
US

IV. Provider business mailing address

2220 1ST AVE
SPRING LAKE NJ
07762-1649
US

V. Phone/Fax

Practice location:
  • Phone: 732-449-5653
  • Fax:
Mailing address:
  • Phone: 732-449-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06559900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: