Provider Demographics
NPI:1083625693
Name:PODKUL, RICHARD LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEON
Last Name:PODKUL
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 1:1064 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2808
Mailing Address - Country:US
Mailing Address - Phone:973-893-0282
Mailing Address - Fax:973-893-0612
Practice Address - Street 1:1064 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2808
Practice Address - Country:US
Practice Address - Phone:973-893-0282
Practice Address - Fax:973-893-0612
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA35781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPO452619Medicare ID - Type Unspecified
NJC55356Medicare UPIN