Provider Demographics
NPI:1700894110
Name:BOGDAN, SERGEY V (MD)
Entity type:Individual
Prefix:DR
First Name:SERGEY
Middle Name:V
Last Name:BOGDAN
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 1:62 KEUNE CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1431
Mailing Address - Country:US
Mailing Address - Phone:718-265-7700
Mailing Address - Fax:718-265-7701
Practice Address - Street 1:8686 BAY PKWY STE M4
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-5193
Practice Address - Country:US
Practice Address - Phone:718-265-7700
Practice Address - Fax:718-265-7701
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222300208VP0014X, 208100000X
NJ25MA0719390208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02176369Medicaid
H46468Medicare UPIN
NY2I0871Medicare ID - Type Unspecified