Provider Demographics
NPI:1689426322
Name:JOHN J BODKIN, II, MD, LLC
Entity Type:Organization
Organization Name:JOHN J BODKIN, II, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BODKIN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:716-689-1864
Mailing Address - Street 1:5667 CREEKWOOD CT EAST
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051
Mailing Address - Country:US
Mailing Address - Phone:716-689-1864
Mailing Address - Fax:
Practice Address - Street 1:5667 CREEKWOOD CT EAST
Practice Address - Street 2:
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051
Practice Address - Country:US
Practice Address - Phone:716-689-1864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00637274Medicaid