Provider Demographics
NPI:1790183077
Name:BODAVULA MD LLC
Entity Type:Organization
Organization Name:BODAVULA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:KR
Authorized Official - Last Name:BODAVULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-563-2943
Mailing Address - Street 1:709 TURRENTINE TRL
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6089
Mailing Address - Country:US
Mailing Address - Phone:914-563-2943
Mailing Address - Fax:
Practice Address - Street 1:709 TURRENTINE TRL
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6089
Practice Address - Country:US
Practice Address - Phone:914-563-2943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010007564261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center