Provider Demographics
NPI:1588714752
Name:BODNER, WILLIAM RAYMOND III (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RAYMOND
Last Name:BODNER
Suffix:III
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 1:193 KEELER DR
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-1009
Mailing Address - Country:US
Mailing Address - Phone:203-790-6637
Mailing Address - Fax:
Practice Address - Street 1:1625 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2653
Practice Address - Country:US
Practice Address - Phone:718-405-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1912492085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01632975Medicaid
NYG13271Medicare UPIN
NY01632975Medicaid