Provider Demographics
NPI:1679887384
Name:BODENHAMER, BRET ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRET
Middle Name:ALLEN
Last Name:BODENHAMER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3238 W TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5708
Mailing Address - Country:US
Mailing Address - Phone:573-635-2020
Mailing Address - Fax:
Practice Address - Street 1:3238 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5708
Practice Address - Country:US
Practice Address - Phone:573-635-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010026679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01311905Medicare PIN
MO7077570001Medicare NSC
MOMA4822003Medicare PIN