Provider Demographics
NPI:1881637999
Name:BODNER, SARA M (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:BODNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 N RAVENSWOOD AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5201
Mailing Address - Country:US
Mailing Address - Phone:312-857-8794
Mailing Address - Fax:
Practice Address - Street 1:4300 ALTON RD
Practice Address - Street 2:MRI BUILDING, 2ND FLOOR
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140
Practice Address - Country:US
Practice Address - Phone:305-674-2194
Practice Address - Fax:305-532-5241
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1435702084A0401X, 2084P0800X
FLME697822084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377478300Medicaid
PA087753Medicare ID - Type Unspecified
PAF96458Medicare UPIN