Provider Demographics
NPI:1093006405
Name:BOHINC, RUDY JORDAN (DO)
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:JORDAN
Last Name:BOHINC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-762-1306
Mailing Address - Fax:937-522-7626
Practice Address - Street 1:540 LINCOLN PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-298-8058
Practice Address - Fax:937-298-5638
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010956207RC0000X, 207RC0000X
OH34010956208M00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103747Medicaid
OHH355801Medicare PIN
OHH311290Medicare PIN