Provider Demographics
NPI:1609515097
Name:BODART, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BODART
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 1:6525 SUNPLEX DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8704
Mailing Address - Country:US
Mailing Address - Phone:813-928-5743
Mailing Address - Fax:
Practice Address - Street 1:6525 SUNPLEX DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-8704
Practice Address - Country:US
Practice Address - Phone:813-928-5743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier