Basic Information
| Provider Information | |||||||||
| NPI: | 1053419135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SASARAN | ||||||||
| FirstName: | BOGDAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189263265 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189263265 | ||||||||
| FaxNumber: | 5189263273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | 217019-1 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0800X | 217019 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 02143295 | 05 | NY | MEDICAID |