Healthcare Provider Details

I. General information

NPI: 1588714752
Provider Name (Legal Business Name): WILLIAM RAYMOND BODNER III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 POPLAR ST
BRONX NY
10461-2653
US

IV. Provider business mailing address

193 KEELER DR
RIDGEFIELD CT
06877-1009
US

V. Phone/Fax

Practice location:
  • Phone: 718-405-8550
  • Fax:
Mailing address:
  • Phone: 203-790-6637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number191249
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: