Provider Demographics
NPI:1811008493
Name:BODMAN, RONALD DUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DUSTIN
Last Name:BODMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 5TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9720
Mailing Address - Country:US
Mailing Address - Phone:541-469-7775
Mailing Address - Fax:541-469-3102
Practice Address - Street 1:586 5TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9720
Practice Address - Country:US
Practice Address - Phone:541-469-7775
Practice Address - Fax:541-469-3102
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2988T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027977Medicaid
OR027977Medicaid
ORV04564Medicare UPIN