Provider Demographics
NPI:1588171318
Name:KHODIK, ROMAN (LAC, MA)
Entity type:Individual
Prefix:MR
First Name:ROMAN
Middle Name:
Last Name:KHODIK
Suffix:
Gender:M
Credentials:LAC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9-09 ELAINE TER
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5714
Mailing Address - Country:US
Mailing Address - Phone:201-707-8025
Mailing Address - Fax:201-791-3508
Practice Address - Street 1:350 W PASSAIC ST STE 2
Practice Address - Street 2:
Practice Address - City:ROCHELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07662-3000
Practice Address - Country:US
Practice Address - Phone:201-880-6207
Practice Address - Fax:201-880-6208
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00128600171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist