Basic Information
| Provider Information | |||||||||
| NPI: | 1386819928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLUSA-SABUGO | ||||||||
| FirstName: | AHGNES | ||||||||
| MiddleName: | UNGOCO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLUSA | ||||||||
| OtherFirstName: | AHGNES | ||||||||
| OtherMiddleName: | UNGOCO | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 134 ELON RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245722536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344552480 | ||||||||
| FaxNumber: | 4344552487 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 FEDERAL ST | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245042306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349475967 | ||||||||
| FaxNumber: | 4344552487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 08/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 266535 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101243921 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03495012 | 05 | NY | MEDICAID |