Provider Demographics
NPI:1245423219
Name:E. JAMES BODMER, D.P.M., PC
Entity Type:Organization
Organization Name:E. JAMES BODMER, D.P.M., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BODMER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:480-363-3066
Mailing Address - Street 1:9765 E DEAD SURE PL
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85218-7176
Mailing Address - Country:US
Mailing Address - Phone:480-363-3066
Mailing Address - Fax:
Practice Address - Street 1:9765 E DEAD SURE PL
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85218-7176
Practice Address - Country:US
Practice Address - Phone:480-363-3066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0152261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0152OtherAZ LICENSE
AZ0152OtherAZ LICENSE