Provider Demographics
NPI:1750851960
Name:BODO, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BODO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 N RACCOON RD APT 40
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2709
Mailing Address - Country:US
Mailing Address - Phone:330-207-1797
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY PLZ
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44555-0001
Practice Address - Country:US
Practice Address - Phone:330-941-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer