Provider Demographics
NPI:1760434740
Name:BODINE, JONATHAN A (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:A
Last Name:BODINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 S ALABAMA ST
Practice Address - Street 2:STE 3B
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2315
Practice Address - Country:US
Practice Address - Phone:406-723-4312
Practice Address - Fax:406-723-4316
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10364207R00000X
IDO-1460207R00000X
WAOP60662799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0153179Medicaid
MTH83571Medicare UPIN