Healthcare Provider Details

I. General information

NPI: 1033340013
Provider Name (Legal Business Name): KIP L BODI PHYSICIAN FACS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2009
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 PARK AVE SUITE 262
HUNTINGTON NY
11743-3976
US

IV. Provider business mailing address

775 PARK AVE SUITE 262
HUNTINGTON NY
11743-3976
US

V. Phone/Fax

Practice location:
  • Phone: 631-271-1608
  • Fax: 631-271-1968
Mailing address:
  • Phone: 631-271-1608
  • Fax: 631-271-1968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number144782
License Number StateNY

VIII. Authorized Official

Name: DR. KIP L BODI
Title or Position: PRESIDENT
Credential: M.D.,F.A.C.S.
Phone: 631-271-1608