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General NPI Number Information
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NPI Number | 1376607713
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Entity Type | Organization
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Legal Business Name | SOUTH ISLAND PODIATRY SPECIALISTS,PC
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 06/13/2008
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Provider Practice Location Address
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Address Line | 1641 ROUTE 112
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City | MEDFORD
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State | NY
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Zip | 11763-3635
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Country | US
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Telephone | 631-447-0800
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Fax | 631-447-0801
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Provider Business Mailing Address
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Address Line | 1641 ROUTE 112
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City | MEDFORD
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State | NY
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Zip | 11763-3635
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Country | US
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Telephone | 631-447-0800
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Fax | 631-447-0801
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WAYNE JOSEPH BODAMER
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Credential | D.P.M.
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Telephone | 631-447-0800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | N0-3889
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License Number State | NY
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