Provider Demographics
NPI:1215068812
Name:BOHATIUK, GEORGE MARK (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MARK
Last Name:BOHATIUK
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 1:500 CHRISTIANA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-1655
Mailing Address - Country:US
Mailing Address - Phone:302-455-1007
Mailing Address - Fax:
Practice Address - Street 1:500 CHRISTIANA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-1655
Practice Address - Country:US
Practice Address - Phone:302-455-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003653208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE740760Medicare ID - Type Unspecified
DEE28489Medicare UPIN