Provider Demographics
NPI:1699790295
Name:BODZIAK, KENNETH A (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:BODZIAK
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-1269
Practice Address - Fax:774-443-7827
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA262575207RN0300X
OK28815207RN0300X
OH35-080029207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110104086AMedicaid
OH4504993OtherAETNA
OH390007777OtherRAILROAD MEDICARE
000000224247OtherUNISON
741798OtherBUCKEYE
000000539531OtherANTHEM
363368OtherWELLCARE
OH2269843Medicaid