Provider Demographics
NPI:1154324820
Name:BODE, SHAWN F (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:F
Last Name:BODE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:MN
Mailing Address - Zip Code:55726-0116
Mailing Address - Country:US
Mailing Address - Phone:218-644-3811
Mailing Address - Fax:218-644-3813
Practice Address - Street 1:5568 CLARK AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:CROMWELL
Practice Address - State:MN
Practice Address - Zip Code:55726-0116
Practice Address - Country:US
Practice Address - Phone:218-644-3811
Practice Address - Fax:218-644-3813
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN40644207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN128716800Medicaid
MN080007334Medicare ID - Type Unspecified
MN128716800Medicaid