Healthcare Provider Details

I. General information

NPI: 1093006405
Provider Name (Legal Business Name): RUDY JORDAN BOHINC DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LINCOLN PARK BLVD STE 200
DAYTON OH
45429
US

IV. Provider business mailing address

1 PRESTIGE PL SUITE 550
MIAMISBURG OH
45342-3794
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-8058
  • Fax: 937-298-5638
Mailing address:
  • Phone: 937-762-1306
  • Fax: 937-522-7626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34.010956
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: