Provider Demographics
NPI:1013977669
Name:BODOR, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BODOR
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 1:308 N PETERS RD
Mailing Address - Street 2:STE 225
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922
Mailing Address - Country:US
Mailing Address - Phone:865-694-0062
Mailing Address - Fax:865-694-7907
Practice Address - Street 1:8 CADILLAC DRIVE
Practice Address - Street 2:STE 200
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027
Practice Address - Country:US
Practice Address - Phone:615-376-7500
Practice Address - Fax:615-376-7575
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD404902085R0202X
FLME666602085R0202X
SD57472085R0202X
MS191952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3336382Medicaid
E84328Medicare UPIN
TN3336382Medicaid