Provider Demographics
NPI:1013059005
Name:DODT, BRUCE I (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:I
Last Name:DODT
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 1:500 N WALL ST STE 300
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2942
Mailing Address - Country:US
Mailing Address - Phone:815-935-0750
Mailing Address - Fax:815-935-8797
Practice Address - Street 1:500 N WALL ST STE 300
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2942
Practice Address - Country:US
Practice Address - Phone:815-935-0750
Practice Address - Fax:815-935-8797
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360602502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060250Medicaid
C45958Medicare UPIN
IL721380Medicare ID - Type Unspecified