Provider Demographics
NPI:1053932566
Name:BODRYA, KRISHNA VALLABHBHAI
Entity type:Individual
Prefix:
First Name:KRISHNA
Middle Name:VALLABHBHAI
Last Name:BODRYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 HECKTOWN RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2355
Mailing Address - Country:US
Mailing Address - Phone:613-333-8888
Mailing Address - Fax:330-841-9645
Practice Address - Street 1:3780 HECKTOWN RD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2355
Practice Address - Country:US
Practice Address - Phone:610-333-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2024-02-06
Deactivation Date:2022-01-11
Deactivation Code:
Reactivation Date:2022-01-27
Provider Licenses
StateLicense IDTaxonomies
PAMD481437207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine