Provider Demographics
NPI:1689673790
Name:BODDIE, ELLENA LOIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLENA
Middle Name:LOIS
Last Name:BODDIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 TECHNOLOGY PARK STE 109
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7107
Mailing Address - Country:US
Mailing Address - Phone:407-647-2346
Mailing Address - Fax:
Practice Address - Street 1:525 TECHNOLOGY PARK STE 109
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-7107
Practice Address - Country:US
Practice Address - Phone:407-647-2346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301502442207R00000X
WY13001A207R00000X
IL036116967208M00000X, 207R00000X
NMTM2020-0627207R00000X
IDM15405207R00000X
AL00041414207R00000X
FLME146842207R00000X
IN01057385A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116967Medicaid
INH87410Medicare UPIN
ILK46133Medicare PIN
ILP00438326OtherMEDICARE RAILROAD
ILK46131Medicare PIN