Provider Demographics
NPI:1831138239
Name:BODE, GREGORY ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:BODE
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2500 W UTOPIA RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4171
Mailing Address - Country:US
Mailing Address - Phone:602-214-6148
Mailing Address - Fax:602-214-6149
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4013
Practice Address - Country:US
Practice Address - Phone:623-780-1999
Practice Address - Fax:623-516-0950
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2013-09-24
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Provider Licenses
StateLicense IDTaxonomies
AZ3615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z8016Medicare ID - Type UnspecifiedMEDICARE
AZ274496Medicare PIN
AZH24842Medicare UPIN