Provider Demographics
NPI:1144231614
Name:BODANZA, TODD J (DC)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:J
Last Name:BODANZA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 HEALTH CARE DR
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-5363
Mailing Address - Country:US
Mailing Address - Phone:727-376-9611
Mailing Address - Fax:727-376-0752
Practice Address - Street 1:1811 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5363
Practice Address - Country:US
Practice Address - Phone:727-376-9611
Practice Address - Fax:727-376-0752
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007068111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3808742000Medicaid
FLU62858Medicare UPIN
FLK8344Medicare ID - Type Unspecified