Provider Demographics
NPI:1801326095
Name:BODNAR, YAROSLAV DANIEL (MD)
Entity type:Individual
Prefix:
First Name:YAROSLAV
Middle Name:DANIEL
Last Name:BODNAR
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 1:5221 PARAMOUNT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5490
Mailing Address - Country:US
Mailing Address - Phone:984-215-4111
Mailing Address - Fax:
Practice Address - Street 1:210 S CAMERON ST
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2505
Practice Address - Country:US
Practice Address - Phone:919-732-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-01939207R00000X, 208000000X
IL125.070456208000000X, 207R00000X
IL036155975208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125.070456OtherTEMPORARY MEDICAL LICENSE