Provider Demographics
NPI:1568493054
Name:BODNAR, MYRON O (MD)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:O
Last Name:BODNAR
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 1:3003 W GOOD HOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:3003 W GOOD HOPE ROAD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-352-3100
Practice Address - Fax:414-247-4597
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29853207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32367100Medicaid
WIP00449418OtherRR MEDICARE
WIP00449418OtherRR MEDICARE
WI32367100Medicaid
G08395Medicare UPIN