Healthcare Provider Details

I. General information

NPI: 1801961834
Provider Name (Legal Business Name): BOHDAN E BODLAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 NW 95TH ST SUITE 204
MIAMI FL
33150-2063
US

IV. Provider business mailing address

209 NE 95TH ST SUITE 3
MIAMI SHORES FL
33138-2745
US

V. Phone/Fax

Practice location:
  • Phone: 305-836-8410
  • Fax: 305-836-9727
Mailing address:
  • Phone: 305-836-8410
  • Fax: 305-836-9727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME53356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: