Provider Demographics
NPI:1053419135
Name:SASARAN, BOGDAN P (MD)
Entity type:Individual
Prefix:
First Name:BOGDAN
Middle Name:P
Last Name:SASARAN
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 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-3265
Mailing Address - Fax:
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-3265
Practice Address - Fax:518-926-3273
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217019-12084A0401X
NY2170192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02143295Medicaid
NY02143295Medicaid