Provider Demographics
NPI:1306266408
Name:BODEK, DANIEL (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BODEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 QUINTON AVE
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-1815
Mailing Address - Country:US
Mailing Address - Phone:203-767-0948
Mailing Address - Fax:
Practice Address - Street 1:1308 MORRIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-3328
Practice Address - Country:US
Practice Address - Phone:908-851-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10134200207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MB10134200OtherNJ LICENSE