Healthcare Provider Details

I. General information

NPI: 1023283140
Provider Name (Legal Business Name): DR. RYAN BODKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 07/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 655
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 655
ROCHESTER NY
14642-8655
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-9555
  • Fax:
Mailing address:
  • Phone: 585-275-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number256630
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: