Provider Demographics
NPI:1396164893
Name:BOGUSH, NIKOLAY
Entity type:Individual
Prefix:
First Name:NIKOLAY
Middle Name:
Last Name:BOGUSH
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 1:1200 E RIDGEWOOD AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3937
Mailing Address - Country:US
Mailing Address - Phone:201-689-9400
Mailing Address - Fax:
Practice Address - Street 1:1200 E RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3957
Practice Address - Country:US
Practice Address - Phone:410-328-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-11
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11396900207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease