Healthcare Provider Details

I. General information

NPI: 1366734808
Provider Name (Legal Business Name): KRISTINE UYESUGI BUGAKOV MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 01/16/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14279 S GLEN OAKS RD
OREGON CITY OR
97045-8008
US

IV. Provider business mailing address

14279 S GLEN OAKS RD
OREGON CITY OR
97045-8008
US

V. Phone/Fax

Practice location:
  • Phone: 503-657-7629
  • Fax: 503-557-8651
Mailing address:
  • Phone: 503-657-7629
  • Fax: 503-557-8651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number172996
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD167908
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500672262
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: