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General NPI Number Information
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NPI Number | 1376525188
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Entity Type | Individual
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Provider Name | WALTER BODJANAC D.O.
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Gender | Male
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Dates
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Enumeration Date | 11/17/2005
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Last Update Date | 06/28/2024
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Provider Practice Location Address
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Address Line | 6316 W UNION HILLS DR STE 200
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City | GLENDALE
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State | AZ
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Zip | 85308-1001
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Country | US
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Telephone | 480-905-8485
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Fax |
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Provider Business Mailing Address
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Address Line | 700 N COLUMBUS ST
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City | CRESTLINE
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State | OH
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Zip | 44827-1455
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Country | US
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Telephone | 419-468-0522
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 34-00-5512-B
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 34-00-5512-B
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License Number State | OH
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