Provider Demographics
NPI:1376536458
Name:BODENHAUSEN, GARY E (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:BODENHAUSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 NO. 7 HIGHWAY
Mailing Address - Street 2:STE B
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014
Mailing Address - Country:US
Mailing Address - Phone:816-229-8880
Mailing Address - Fax:816-229-4363
Practice Address - Street 1:104 NO. 7 HIGHWAY
Practice Address - Street 2:STE B
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014
Practice Address - Country:US
Practice Address - Phone:816-229-8880
Practice Address - Fax:816-229-4363
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR6442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO06616078OtherBC/BS
MO1023793OtherAETNA
MO06616078OtherBC/BS
MO1023793OtherAETNA