Provider Demographics
NPI:1871550012
Name:REGENBOGEN, VICTOR S (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:S
Last Name:REGENBOGEN
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 1:111 N MAPLEMERE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3178
Mailing Address - Country:US
Mailing Address - Phone:716-836-4646
Mailing Address - Fax:716-859-2962
Practice Address - Street 1:111 N MAPLEMERE RD STE 120
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3178
Practice Address - Country:US
Practice Address - Phone:716-836-4646
Practice Address - Fax:716-859-2962
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1715492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01044453Medicaid
00026030204OtherUNIVERA
0142857OtherGHI
000911571014OtherBLUE SHIELD WNY
040426003059OtherFIDELIS
1693153OtherINDEPENDENT HEALTH
P00029526OtherRR MEDICARE
4195928OtherGHI
P010171549OtherBLUE CHOICE
101203FFOtherPREFERRED CARE
00026030202OtherUNIVERA
000911571011OtherBLUE SHIELD WNY
NY1715499BOtherWORKERS COMPENSATION
P020171549OtherBLUE SHIELD ROCHESTER
P00136831OtherRR MEDICARE
NY1715499BOtherWORKERS COMPENSATION
NY01044453Medicaid
P00136831OtherRR MEDICARE
NYB81037Medicare UPIN