Provider Demographics
NPI:1720669625
Name:BODKIN, BRIAN
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:BODKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26229 N CRANES MILL RD
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133-1957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26229 N CRANES MILL RD
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78133-1957
Practice Address - Country:US
Practice Address - Phone:830-935-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4170-4171171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator