Healthcare Provider Details

I. General information

NPI: 1427199140
Provider Name (Legal Business Name): KENNETH ALAN BODKIN AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE. DEPT. OF AUDIOLOGY
HACKENSACK NJ
07601
US

IV. Provider business mailing address

20 PROSPECT AVE SUITE 808
HACKENSACK NJ
07601-1997
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-5126
  • Fax: 201-996-0557
Mailing address:
  • Phone: 201-996-5126
  • Fax: 201-996-0557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1552
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberYA000577
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number25MG00090100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: