Healthcare Provider Details

I. General information

NPI: 1376525188
Provider Name (Legal Business Name): WALTER BODJANAC D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6316 W UNION HILLS DR STE 200
GLENDALE AZ
85308-1001
US

IV. Provider business mailing address

700 N COLUMBUS ST
CRESTLINE OH
44827-1455
US

V. Phone/Fax

Practice location:
  • Phone: 480-905-8485
  • Fax:
Mailing address:
  • Phone: 419-468-0522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34-00-5512-B
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number34-00-5512-B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: