Healthcare Provider Details

I. General information

NPI: 1043228349
Provider Name (Legal Business Name): BULENT MAMIKOGLU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/03/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WEBSTER AVE STE 307
POUGHKEEPSIE NY
12601-1365
US

IV. Provider business mailing address

4495 MIDDLE CHESHIRE RD
CANANDAIGUA NY
14424-8327
US

V. Phone/Fax

Practice location:
  • Phone: 914-693-7636
  • Fax:
Mailing address:
  • Phone: 815-993-4266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberE3010
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036117864
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberE3010
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number303313
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: