Basic Information
| Provider Information | |||||||||
| NPI: | 1205885076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODARY | ||||||||
| FirstName: | A | ||||||||
| MiddleName: | KIRK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2001 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154490513 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1065 SENATOR KEATING BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852561330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 177508 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01134418 | 05 | NY | MEDICAID |