Provider Demographics
NPI:1366614406
Name:BODNER, BRADLEY A (DO)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:BODNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 STATE ROUTE 34 STE 4
Mailing Address - Street 2:
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-4262
Mailing Address - Country:US
Mailing Address - Phone:732-333-8155
Mailing Address - Fax:
Practice Address - Street 1:65 STATE ROUTE 34 STE 4
Practice Address - Street 2:
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-4262
Practice Address - Country:US
Practice Address - Phone:732-333-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 8450208100000X
NJ25MB08845000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation