Healthcare Provider Details

I. General information

NPI: 1851414031
Provider Name (Legal Business Name): DMITRI BOUGAKOV PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 57TH ST SUITE 401
NEW YORK NY
10019-3158
US

IV. Provider business mailing address

315 W 57TH ST SUITE 401
NEW YORK NY
10019-3158
US

V. Phone/Fax

Practice location:
  • Phone: 646-496-8963
  • Fax:
Mailing address:
  • Phone: 646-496-8963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number68 017107
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: