Provider Demographics
NPI:1336136670
Name:IMBODY, BRENT WILSON (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:WILSON
Last Name:IMBODY
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 1:136 S LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1813
Mailing Address - Country:US
Mailing Address - Phone:937-499-8262
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:330 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4465
Practice Address - Country:US
Practice Address - Phone:937-435-1445
Practice Address - Fax:937-439-7552
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.063723207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0909057Medicaid
F31596Medicare UPIN
OH0909057Medicaid
OHH082570Medicare PIN