Provider Demographics
NPI:1902031628
Name:BODLE, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BODLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 CLEMENTS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8322
Mailing Address - Country:US
Mailing Address - Phone:317-439-4352
Mailing Address - Fax:
Practice Address - Street 1:1951 CLEMENTS FERRY RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29492-8322
Practice Address - Country:US
Practice Address - Phone:317-439-4352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-003722084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1902031628Medicaid
SCNC2336Medicaid
SCNC2336Medicaid
NCNCD064BMedicare PIN
NCNCD064C904Medicare PIN