Provider Demographics
NPI:1164449674
Name:BODNER, MATTHEW S (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:S
Last Name:BODNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 GILMER PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TALLASSEE
Mailing Address - State:AL
Mailing Address - Zip Code:36078-1215
Mailing Address - Country:US
Mailing Address - Phone:334-731-4500
Mailing Address - Fax:
Practice Address - Street 1:5 GILMER PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:TALLASSEE
Practice Address - State:AL
Practice Address - Zip Code:36078-1215
Practice Address - Country:US
Practice Address - Phone:334-731-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5J60207L00000X
AL10657207L00000X
WI50121-20207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202646105Medicaid
MO202646105Medicaid