Provider Demographics
NPI:1417944208
Name:BODKER, FRED S (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:S
Last Name:BODKER
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:PO BOX 803861
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-3861
Mailing Address - Country:US
Mailing Address - Phone:913-341-3100
Mailing Address - Fax:913-341-6818
Practice Address - Street 1:7504 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-2622
Practice Address - Country:US
Practice Address - Phone:913-341-3100
Practice Address - Fax:913-341-6818
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04/25774174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
180022395OtherRAILROAD MEDICARE
KS2258848Medicare ID - Type Unspecified
180022395OtherRAILROAD MEDICARE