Provider Demographics
NPI:1659350296
Name:BODDE, GERALD (LPT)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:
Last Name:BODDE
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MIDWESTERN PKWY E
Mailing Address - Street 2:ATTN: PATTI SEARLES
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-2302
Mailing Address - Country:US
Mailing Address - Phone:940-766-8435
Mailing Address - Fax:940-766-8497
Practice Address - Street 1:4601 JACKSBORO HWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2921
Practice Address - Country:US
Practice Address - Phone:940-723-3117
Practice Address - Fax:940-723-3140
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T2885OtherBCBS PROVIDER NUMBER
TX8D3674Medicare ID - Type UnspecifiedMEDICARE