Provider Demographics
NPI:1386642536
Name:BODRERO, KEITH O (DO)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:O
Last Name:BODRERO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 N CAREFREE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2402
Mailing Address - Country:US
Mailing Address - Phone:719-550-9100
Mailing Address - Fax:719-380-0384
Practice Address - Street 1:6080 N CAREFREE CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2402
Practice Address - Country:US
Practice Address - Phone:719-550-9100
Practice Address - Fax:719-380-0384
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2013-08-29
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
CO32687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01326875Medicaid
CO01326875Medicaid
COC512358Medicare PIN