Provider Demographics
NPI:1447847942
Name:BUGNO, DERIK M
Entity type:Individual
Prefix:
First Name:DERIK
Middle Name:M
Last Name:BUGNO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4852 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-1171
Mailing Address - Country:US
Mailing Address - Phone:303-955-0124
Mailing Address - Fax:
Practice Address - Street 1:4852 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-1171
Practice Address - Country:US
Practice Address - Phone:303-955-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization