Provider Demographics
NPI:1538371745
Name:BOGAVELLI, KISHANRAO (MD)
Entity type:Individual
Prefix:
First Name:KISHANRAO
Middle Name:
Last Name:BOGAVELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 TEMPLE HILL RD
Mailing Address - Street 2:STE 102
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-5557
Mailing Address - Country:US
Mailing Address - Phone:845-565-3700
Mailing Address - Fax:845-565-3395
Practice Address - Street 1:680 BROADWAY
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1422
Practice Address - Country:US
Practice Address - Phone:973-977-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA44068207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3721205Medicaid
NJ661638Medicare ID - Type Unspecified
NJ37725Medicare UPIN