Provider Demographics
NPI:1457317562
Name:BODAMER, WAYNE JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:JOSEPH
Last Name:BODAMER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1641 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3635
Mailing Address - Country:US
Mailing Address - Phone:631-447-0800
Mailing Address - Fax:631-447-0801
Practice Address - Street 1:373 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4759
Practice Address - Country:US
Practice Address - Phone:631-265-8802
Practice Address - Fax:631-265-8809
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003889213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPPD162OtherHEALTHNET
NYAH00139OtherMDNY
NYP41901OtherEMPIRE BLUECROSS/BLUE SHI
NY0056853OtherGHI
NY0301399-007OtherCIGNA HMO
NY96401OtherAETNA US HEALTHCARE
NYP368761OtherOXFORD HEALTH PLAN
NYP41901Medicare PIN
NY0301399-007OtherCIGNA HMO
NY96401OtherAETNA US HEALTHCARE