Provider Demographics
NPI:1508913120
Name:WASILJEW, BOHDAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:BOHDAN
Middle Name:K
Last Name:WASILJEW
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 1:510 N TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2906
Mailing Address - Country:US
Mailing Address - Phone:608-756-7277
Mailing Address - Fax:
Practice Address - Street 1:510 N TERRACE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2906
Practice Address - Country:US
Practice Address - Phone:608-756-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34717208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31953600Medicaid
WI31953600Medicaid