Provider Demographics
NPI:1265827869
Name:BODENLOS, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BODENLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 OLD SHORT HILLS RD
Mailing Address - Street 2:EAST WING, SUITE 402
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-1962
Mailing Address - Country:US
Mailing Address - Phone:973-322-5287
Mailing Address - Fax:
Practice Address - Street 1:94 OLD SHORT HILLS RD
Practice Address - Street 2:EAST WING, SUITE 402
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-1962
Practice Address - Country:US
Practice Address - Phone:973-322-5287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10539800207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program