Provider Demographics
NPI:1457319642
Name:BODKER, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
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 1:2830 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1042
Mailing Address - Country:US
Mailing Address - Phone:602-274-1919
Mailing Address - Fax:602-274-0804
Practice Address - Street 1:2830 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1042
Practice Address - Country:US
Practice Address - Phone:602-274-1919
Practice Address - Fax:602-274-0804
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2015-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ136152085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0324990OtherBCBS
AZ245789OtherAHCCCS
AZ1Z7049OtherHEALTHNET
AZAZ0324990OtherBCBS
AZD43716Medicare UPIN