Basic Information
| Provider Information | |||||||||
| NPI: | 1679649735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODIAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 NEW DORP LN | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103062351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183703500 | ||||||||
| FaxNumber: | 7189795236 | ||||||||
| Practice Location | |||||||||
| Address1: | 2133 RALPH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112345405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184511400 | ||||||||
| FaxNumber: | 7184512797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 013808-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.