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General NPI Number Information
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NPI Number | 1457317562
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Entity Type | Individual
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Provider Name | WAYNE JOSEPH BODAMER D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 11/27/2007
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Provider Practice Location Address
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Address Line | 373 ROUTE 111
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City | SMITHTOWN
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State | NY
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Zip | 11787-4759
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Country | US
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Telephone | 631-265-8802
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Fax | 631-265-8809
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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 |
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 003889
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License Number State | NY
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