Provider Demographics
NPI:1851580823
Name:BODENSTEINER, SALLY (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BODENSTEINER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1340
Mailing Address - Country:US
Mailing Address - Phone:812-882-1106
Mailing Address - Fax:812-885-2758
Practice Address - Street 1:406 N 1ST ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1340
Practice Address - Country:US
Practice Address - Phone:812-882-1106
Practice Address - Fax:812-885-2758
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074304A207Q00000X
NMMD2008-0602208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01074304AOtherINDIANA LICENSE
IN201260890Medicaid
IN000000898810OtherANTHEM
IN258190OtherMEDICARE GROUP
IN01074304AOtherINDIANA LICENSE