Provider Demographics
NPI:1386635829
Name:BODACK, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:BODACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1 WEBSTER AVE
Mailing Address - Street 2:ATRIUM AT SFH
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1363
Mailing Address - Country:US
Mailing Address - Phone:845-483-5780
Mailing Address - Fax:845-483-5787
Practice Address - Street 1:1 WEBSTER AVE
Practice Address - Street 2:ATRIUM AT SFH
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1361
Practice Address - Country:US
Practice Address - Phone:845-483-5780
Practice Address - Fax:845-483-5787
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2022-03-01
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Provider Licenses
StateLicense IDTaxonomies
NY196328208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01849729Medicaid
NYF87049Medicare UPIN
NY01849729Medicaid