Provider Demographics
NPI:1700822673
Name:BODINE, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BODINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7253 AMBASSADOR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2710
Mailing Address - Country:US
Mailing Address - Phone:443-436-1151
Mailing Address - Fax:443-436-1256
Practice Address - Street 1:7253 AMBASSADOR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2710
Practice Address - Country:US
Practice Address - Phone:443-436-1151
Practice Address - Fax:443-436-1256
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00287202085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD369291400Medicaid
MD369291400Medicaid
300076090Medicare PIN
D77841Medicare UPIN