Provider Demographics
NPI:1336225630
Name:DOBERCZAK, BOHDAN WSEWOLOD (MD)
Entity type:Individual
Prefix:DR
First Name:BOHDAN
Middle Name:WSEWOLOD
Last Name:DOBERCZAK
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 1:7900 OLD YORK RD
Mailing Address - Street 2:APARTMENT 105A
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2318
Mailing Address - Country:US
Mailing Address - Phone:215-224-3330
Mailing Address - Fax:215-641-9987
Practice Address - Street 1:7900 OLD YORK RD
Practice Address - Street 2:APARTMENT 105A
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2318
Practice Address - Country:US
Practice Address - Phone:215-224-3330
Practice Address - Fax:215-641-9987
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020681E2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00050626OtherRAILROAD MEDICARE
PA0046255000OtherPERSONAL CHOICE
PA11559069OtherCAQH
PA016746Medicare ID - Type UnspecifiedMEDICARE
PAP00050626OtherRAILROAD MEDICARE