Provider Demographics
NPI:1609019405
Name:BODDY, BRIAN K
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:BODDY
Suffix:
Gender:M
Credentials:
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 6079
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6079
Mailing Address - Country:US
Mailing Address - Phone:505-471-2020
Mailing Address - Fax:505-473-5103
Practice Address - Street 1:3530 ZAFARANO DR STE C1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2609
Practice Address - Country:US
Practice Address - Phone:505-471-2020
Practice Address - Fax:505-473-5103
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician