Provider Demographics
NPI:1710100045
Name:BODE, KENNETH SPENCER (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SPENCER
Last Name:BODE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-5586
Mailing Address - Fax:210-916-5102
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-5586
Practice Address - Fax:210-916-5102
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU1474207X00000X, 207XS0117X
CAA122470207XS0117X
WAMD60635856207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA122470OtherSTATE LICENCE
TXU1474OtherSTATE LICENSE
WAMD60635856OtherSTATE