Provider Demographics
NPI:1376530774
Name:BODDIE, PATRICE D (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:D
Last Name:BODDIE
Suffix:
Gender:F
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:PO BOX 1219
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-1219
Mailing Address - Country:US
Mailing Address - Phone:478-452-6999
Mailing Address - Fax:478-452-7222
Practice Address - Street 1:240 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3438
Practice Address - Country:US
Practice Address - Phone:478-452-6999
Practice Address - Fax:478-452-7222
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00316852BMedicaid
GA00316852AMedicaid
GA581759458OtherTAX PAYER ID
GA52238029OtherBLUE CROSS/BLUE SHIELD
GA00316852AMedicaid
GA11BDCBCMedicare ID - Type UnspecifiedPROVIDER NUMBER