Provider Demographics
NPI:1386052843
Name:BOGOCH, SALLY HANNA (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:HANNA
Last Name:BOGOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:311 BALTIC ST
Mailing Address - Street 2:APARTMENT 1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6482
Mailing Address - Country:US
Mailing Address - Phone:917-580-0967
Mailing Address - Fax:718-245-4799
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:MAIMONIDES MEDICAL CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY283531207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program