Provider Demographics
NPI:1033173158
Name:BODE, JOHN NICHOLAS (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:NICHOLAS
Last Name:BODE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17 W BOCA RATON RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-6210
Mailing Address - Country:US
Mailing Address - Phone:602-548-7010
Mailing Address - Fax:602-548-7020
Practice Address - Street 1:17 W BOCA RATON RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-6210
Practice Address - Country:US
Practice Address - Phone:602-548-7010
Practice Address - Fax:602-548-7020
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ15232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C98154Medicare UPIN