Provider Demographics
NPI:1396738456
Name:MINCZAK, BOHDAN M (MD)
Entity type:Individual
Prefix:
First Name:BOHDAN
Middle Name:M
Last Name:MINCZAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1320
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:245 N 15TH STREET
Practice Address - Street 2:NCB ROOM 2108
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-762-2361
Practice Address - Fax:215-762-1307
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064462L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8523801Medicaid
PA0017079530005Medicaid
PA017491Medicare ID - Type Unspecified
PA0017079530005Medicaid