Healthcare Provider Details

I. General information

NPI: 1073891081
Provider Name (Legal Business Name): PETER R. BODNAR, M.D. PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6544 E CARONDELET DR
TUCSON AZ
85710-2117
US

IV. Provider business mailing address

6544 E CARONDELET DR
TUCSON AZ
85710-2117
US

V. Phone/Fax

Practice location:
  • Phone: 520-333-7723
  • Fax: 520-333-3113
Mailing address:
  • Phone: 520-333-7723
  • Fax: 520-333-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25515
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number25515
License Number StateAZ

VIII. Authorized Official

Name: DR. PETER BODNAR
Title or Position: MANAGER
Credential: M.D.
Phone: 520-333-7723