Provider Demographics
NPI:1992797096
Name:FEDCZUK, BOHDAN (MD)
Entity type:Individual
Prefix:
First Name:BOHDAN
Middle Name:
Last Name:FEDCZUK
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-2209
Practice Address - Street 1:27 PARK AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1605
Practice Address - Country:US
Practice Address - Phone:607-772-6266
Practice Address - Fax:607-772-8567
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162722208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01191386Medicaid
NY01191386Medicaid
NY56709VMedicare PIN