Provider Demographics
NPI:1679617393
Name:BODAK, JOAN M
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:BODAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 W LAYTON AVE
Mailing Address - Street 2:#847
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80123-1301
Mailing Address - Country:US
Mailing Address - Phone:303-948-3702
Mailing Address - Fax:
Practice Address - Street 1:8383 W ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3007
Practice Address - Country:US
Practice Address - Phone:303-239-7358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO66374207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
005482OtherKAISER-COMMERCIAL NUMBER