Provider Demographics
NPI:1386953446
Name:BOGOLJUBSKIJ, SERGIO
Entity type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:
Last Name:BOGOLJUBSKIJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ROOSEVELT AVENUE
Mailing Address - Street 2:COND ESCORIAL APT 6 A
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-2714
Mailing Address - Country:US
Mailing Address - Phone:787-318-4442
Mailing Address - Fax:
Practice Address - Street 1:111 MARGINAL AVE FD ROOSEVELT
Practice Address - Street 2:6 A COND ESCORIAL
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-2736
Practice Address - Country:US
Practice Address - Phone:787-318-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7046172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist