Provider Demographics
NPI:1013027671
Name:BODENHEIMER, MONTY MAX (MD)
Entity Type:Individual
Prefix:DR
First Name:MONTY
Middle Name:MAX
Last Name:BODENHEIMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3003 NEW HYDE PARK RD
Mailing Address - Street 2:STE 406
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1214
Mailing Address - Country:US
Mailing Address - Phone:516-719-0102
Mailing Address - Fax:516-358-5403
Practice Address - Street 1:3003 NEW HYDE PARK RD
Practice Address - Street 2:STE 406
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1214
Practice Address - Country:US
Practice Address - Phone:516-719-0102
Practice Address - Fax:516-358-5403
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153049207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY919553Medicaid
B88368Medicare UPIN
NY919553Medicaid