Provider Demographics
NPI:1982689428
Name:BODI, KIP LORD (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:KIP
Middle Name:LORD
Last Name:BODI
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 PULASKI RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1602
Mailing Address - Country:US
Mailing Address - Phone:631-271-1608
Mailing Address - Fax:631-271-1968
Practice Address - Street 1:284 PULASKI RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1602
Practice Address - Country:US
Practice Address - Phone:631-271-1608
Practice Address - Fax:631-271-1968
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144782174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB14386Medicare UPIN
NY42D742Medicare PIN