Provider Demographics
NPI:1598178352
Name:BODELL, BRYCEN D (MD)
Entity Type:Individual
Prefix:
First Name:BRYCEN
Middle Name:D
Last Name:BODELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRYCE
Other - Middle Name:
Other - Last Name:BODELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:925 E MCDOWELL RD FL 2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2502
Mailing Address - Country:US
Mailing Address - Phone:602-839-3339
Mailing Address - Fax:602-839-3300
Practice Address - Street 1:8701 W WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3548
Practice Address - Country:US
Practice Address - Phone:414-955-4575
Practice Address - Fax:414-955-6409
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67931-202085R0202X
AZR74636208600000X
COTL.000865390200000X
WI679312085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program