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
State | License ID | Taxonomies |
---|---|---|
MD | D61706 | 2085R0204X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 405055000 | Medicaid | |
MD | H380I849 | Medicare PIN | |
MD | P00203175 | Medicare PIN | |
MD | 405055000 | Medicaid | |
MD | I849 | Medicare ID - Type Unspecified | MEDICARE IPIN |