Provider Demographics
NPI:1871607218
Name:BODZIN, STANLEY S (DPM)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:S
Last Name:BODZIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BERLIN RD
Mailing Address - Street 2:SUITE 5000
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3574
Mailing Address - Country:US
Mailing Address - Phone:856-795-1003
Mailing Address - Fax:856-795-5994
Practice Address - Street 1:52 BERLIN RD
Practice Address - Street 2:SUITE 5000
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-3574
Practice Address - Country:US
Practice Address - Phone:856-795-1003
Practice Address - Fax:856-795-5994
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001895L213E00000X
NJMD103700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6201283OtherGROUP HEALTH INSURANCE
NJ0495000Medicaid
15222OtherUNIVERSITY HEALTH PLAN
OXFORDOtherP3065606
PA066165OtherIBC
PA48674OtherKEYSTONE MERCY HEALTH PLA
0060537000OtherAMERIHEALTH
27-00990OtherEVERCARE
PASC001895LOtherHEALTH PARTNERS
NJ0000571094Medicare NSC
OXFORDOtherP3065606
27-00990OtherEVERCARE
PA066165OtherIBC
PA0000066165Medicare NSC