Provider Demographics
NPI:1255693065
Name:BODENBURG, GARY CHARLES (MSED)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:CHARLES
Last Name:BODENBURG
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 RULAND RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2301
Mailing Address - Country:US
Mailing Address - Phone:631-846-4810
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLAZA
Practice Address - Street 2:350
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:516-393-9116
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1748234174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist