Provider Demographics
NPI:1437182466
Name:ILIESCU, BOGDAN MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:BOGDAN
Middle Name:MANUEL
Last Name:ILIESCU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17383
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1383
Mailing Address - Country:US
Mailing Address - Phone:410-328-5656
Mailing Address - Fax:410-328-2115
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:ROOM N2E23
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-5656
Practice Address - Fax:410-328-2115
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD617062085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405055000Medicaid
MDH380I849Medicare PIN
MDP00203175Medicare PIN
MD405055000Medicaid
MDI849Medicare ID - Type UnspecifiedMEDICARE IPIN