Basic Information
| Provider Information | |||||||||
| NPI: | 1730131103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGARDUS | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 TEMPLE ST | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065102715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037770304 | ||||||||
| FaxNumber: | 2034014687 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 TEMPLE ST | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065102715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037770304 | ||||||||
| FaxNumber: | 2034014687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 034398 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001343988 | 05 | CT | MEDICAID |