Provider Demographics
NPI:1457642134
Name:BODENHEIMER, NICHOLAS BARRETT (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:BARRETT
Last Name:BODENHEIMER
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-721-4050
Mailing Address - Fax:910-721-4051
Practice Address - Street 1:584 HOSPITAL DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-9047
Practice Address - Country:US
Practice Address - Phone:910-721-4050
Practice Address - Fax:910-721-4051
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
NC201500279207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program