Provider Demographics
NPI:1568730919
Name:BODNER, YAAKOV
Entity Type:Individual
Prefix:
First Name:YAAKOV
Middle Name:
Last Name:BODNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 EDISON CT
Mailing Address - Street 2:P
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-1965
Mailing Address - Country:US
Mailing Address - Phone:845-578-4022
Mailing Address - Fax:
Practice Address - Street 1:34 EDISON CT
Practice Address - Street 2:P
Practice Address - City:MONSEY
Practice Address - State:NY
Practice Address - Zip Code:10952-1965
Practice Address - Country:US
Practice Address - Phone:845-578-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP78065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY555907459OtherDRIVERS LICENSE