Provider Demographics
NPI:1073903803
Name:BODAR, VIPUL
Entity Type:Individual
Prefix:
First Name:VIPUL
Middle Name:
Last Name:BODAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1501 SAN PEDRO DR SE # 2C-100
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5180
Practice Address - Country:US
Practice Address - Phone:505-272-3120
Practice Address - Fax:505-265-1711
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65444-20207R00000X
NMMD2016-05852083C0008X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics