Provider Demographics
NPI:1376525188
Name:BODJANAC, WALTER (DO)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:BODJANAC
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 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:419-468-0522
Mailing Address - Fax:
Practice Address - Street 1:715 RICHLAND MALL
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-3802
Practice Address - Country:US
Practice Address - Phone:419-756-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-5512-B208600000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0161355Medicaid
OH2171126OtherAETNA GOLDEN
OH000000141877OtherANTHEM
OH1143537003OtherCIGNA
OH91970OtherQUAL CHOICE
OH5489782OtherAETNA MGD CHOICE
OH1143537003OtherCIGNA
OHG03287Medicare UPIN