Provider Demographics
NPI:1376742957
Name:BODMAN, MARC G (MD)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:G
Last Name:BODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 61199
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-1199
Mailing Address - Country:US
Mailing Address - Phone:239-418-0999
Mailing Address - Fax:239-418-0091
Practice Address - Street 1:12731 NEW BRITTANY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3632
Practice Address - Country:US
Practice Address - Phone:239-418-0999
Practice Address - Fax:239-418-0091
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT046489207W00000X
LAMD.201176207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00601031Medicaid
LA1508098Medicaid
LA1508098Medicaid
LA4M286Medicare PIN