Provider Demographics
NPI:1093984767
Name:WALTER G. BODJANAC, DO, LLC
Entity Type:Organization
Organization Name:WALTER G. BODJANAC, DO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAUN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SKYRM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-773-3544
Mailing Address - Street 1:358 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44301-2602
Mailing Address - Country:US
Mailing Address - Phone:330-773-3544
Mailing Address - Fax:330-773-3698
Practice Address - Street 1:770 BALGREEN DR
Practice Address - Street 2:SUITE 109
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4106
Practice Address - Country:US
Practice Address - Phone:419-756-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005512208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9357821Medicare PIN