Provider Demographics
NPI:1225088230
Name:BODDIE, KENNETH WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:BODDIE
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 1:1215 S GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3638
Mailing Address - Country:US
Mailing Address - Phone:213-387-9400
Mailing Address - Fax:
Practice Address - Street 1:639 S HAMPSHIRE AVE 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005
Practice Address - Country:US
Practice Address - Phone:213-387-9400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40741225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG40741BMedicare ID - Type UnspecifiedPPIN
CAA92204Medicare UPIN