Provider Demographics
NPI:1871587923
Name:BODEK, KENNETH EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:BODEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-277-2000
Mailing Address - Fax:336-277-2050
Practice Address - Street 1:186 KIMEL PARK DR
Practice Address - Street 2:SUITE 400
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-277-2000
Practice Address - Fax:336-277-2050
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2013-01642207RC0000X
PAMD046703L207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA024733E15OtherMEDICARE
PA0012804190005Medicaid
PAF24888Medicare UPIN
PA0012804190005Medicaid
PAP00021239Medicare PIN