Provider Demographics
NPI:1083766125
Name:MLODZIK, BOGDAN KRYZYSZTOF (MD)
Entity Type:Individual
Prefix:
First Name:BOGDAN
Middle Name:KRYZYSZTOF
Last Name:MLODZIK
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 1:547 W FORT ISLAND TRAIL
Mailing Address - Street 2:SUITE C
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429
Mailing Address - Country:US
Mailing Address - Phone:352-564-0660
Mailing Address - Fax:352-564-0711
Practice Address - Street 1:547 W FORT ISLAND TRAIL
Practice Address - Street 2:SUITE C
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429
Practice Address - Country:US
Practice Address - Phone:352-564-0660
Practice Address - Fax:352-564-0711
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00706392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00032168Medicare ID - Type Unspecified
G18809Medicare UPIN