Provider Demographics
NPI:1518351410
Name:BODEPUDI, HAREN (MD)
Entity Type:Individual
Prefix:
First Name:HAREN
Middle Name:
Last Name:BODEPUDI
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 9033
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-9033
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-781-2716
Practice Address - Street 1:10050 SW INNOVATION WAY STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2117
Practice Address - Country:US
Practice Address - Phone:772-344-3811
Practice Address - Fax:772-344-3890
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME145133207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106666500Medicaid