Provider Demographics
NPI:1942290705
Name:BEDNARZ, MICHAEL K (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:K
Last Name:BEDNARZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1555 DOCTORS DR
Mailing Address - Street 2:STE. 106
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4132
Mailing Address - Country:US
Mailing Address - Phone:706-845-9370
Mailing Address - Fax:706-845-9371
Practice Address - Street 1:120 N MEDICAL PKWY
Practice Address - Street 2:BLDG 100, SUITE 102
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-7062
Practice Address - Country:US
Practice Address - Phone:770-926-4641
Practice Address - Fax:770-926-1692
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPOD001030213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA908119435AMedicaid
LA1756326Medicaid
V06026Medicare UPIN
GA202I485355Medicare PIN