Provider Demographics
NPI:1861970766
Name:BODZISLAW, MARK EUGENE (LAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:BODZISLAW
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13143 PUTNAM CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-1026
Mailing Address - Country:US
Mailing Address - Phone:727-692-3880
Mailing Address - Fax:
Practice Address - Street 1:2111 EISENHOWER AVE STE 402
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4679
Practice Address - Country:US
Practice Address - Phone:703-717-9088
Practice Address - Fax:703-717-9158
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000889171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist