Provider Demographics
NPI:1508807447
Name:BODOUTCHIAN, ANI A (MD)
Entity Type:Individual
Prefix:DR
First Name:ANI
Middle Name:A
Last Name:BODOUTCHIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:120 ROUTE 109
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6210
Mailing Address - Country:US
Mailing Address - Phone:631-422-3636
Mailing Address - Fax:631-422-2788
Practice Address - Street 1:120 ROUTE 109
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6210
Practice Address - Country:US
Practice Address - Phone:631-422-3636
Practice Address - Fax:631-422-2788
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY210217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1317543OtherCIGNA
NY104807OtherVYTRA
NYP2000685OtherOXFORD
NY080149262OtherRAILROAD MEDICARE
NY2C5668OtherHEALTH NET
NY102407OtherAETNA US HEALTHCARE
NY5443340002OtherMEDICARE DME
NY5998961OtherGHI
NY01944994Medicaid
NY080149262OtherRAILROAD MEDICARE
NY01944994Medicaid