Healthcare Provider Details

I. General information

NPI: 1104311612
Provider Name (Legal Business Name): JOSEPH M BODNAR DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 ROUTE 70
MEDFORD NJ
08055
US

IV. Provider business mailing address

1377 MOTOR PKWY STE 307
ISLANDIA NY
11749-5258
US

V. Phone/Fax

Practice location:
  • Phone: 856-533-0920
  • Fax:
Mailing address:
  • Phone: 163-158-0520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01796000
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: