Provider Demographics
NPI:1164935763
Name:BODKIN, STEPHAN (MED, ATC)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:
Last Name:BODKIN
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1657 WICKLIFFE RD
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22611-2558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 EMMET ST S
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2455
Practice Address - Country:US
Practice Address - Phone:434-924-6184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260023572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer