Provider Demographics
NPI:1033196084
Name:BODNARCHUK, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BODNARCHUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6961
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:1532 LONE OAK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7913
Practice Address - Country:US
Practice Address - Phone:270-443-0777
Practice Address - Fax:270-443-0999
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28275207RG0100X
IL036.075177207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075177Medicaid
KY64282759Medicaid
KYP00947881OtherRAIL ROAD MEDICARE
KYP400042958Medicare PIN
KYP00947881OtherRAIL ROAD MEDICARE