Provider Demographics
NPI:1518123421
Name:BODKIN, KEVIN SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SCOTT
Last Name:BODKIN
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 1:4900 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-4605
Mailing Address - Country:US
Mailing Address - Phone:219-237-5170
Mailing Address - Fax:219-321-1931
Practice Address - Street 1:4900 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-4605
Practice Address - Country:US
Practice Address - Phone:419-696-6000
Practice Address - Fax:419-696-6018
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009615207Q00000X
IN02005742A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2996530Medicaid
OH2996530Medicaid