Provider Demographics
NPI:1720358054
Name:BODTKER, BRIAN EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:BODTKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 NE CORNELL RD
Mailing Address - Street 2:300
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5412
Mailing Address - Country:US
Mailing Address - Phone:503-924-1777
Mailing Address - Fax:503-924-2778
Practice Address - Street 1:6125 NE CORNELL RD
Practice Address - Street 2:300
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5412
Practice Address - Country:US
Practice Address - Phone:503-924-1777
Practice Address - Fax:503-924-2778
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor