Provider Demographics
NPI:1518050590
Name:BODMER, DAVID S (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:BODMER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 N MARKET ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-1924
Mailing Address - Country:US
Mailing Address - Phone:570-716-0939
Mailing Address - Fax:570-507-8463
Practice Address - Street 1:29 N MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-1924
Practice Address - Country:US
Practice Address - Phone:570-716-0939
Practice Address - Fax:570-507-8463
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004288L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U70560Medicare UPIN
PA5778120001Medicare NSC
PA142921Medicare PIN