Provider Demographics
NPI:1770588741
Name:BODUCH, THOMAS FRANCIS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FRANCIS
Last Name:BODUCH
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:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-1030
Mailing Address - Country:US
Mailing Address - Phone:865-376-1212
Mailing Address - Fax:865-376-0010
Practice Address - Street 1:314 E SPRING ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2839
Practice Address - Country:US
Practice Address - Phone:865-376-1212
Practice Address - Fax:865-376-0010
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14330207Q00000X
TNMD0000014330208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0086951OtherBLUECROSS BLUESHIELD OF TENNESSEE
TN3004412Medicaid
TN0086951OtherBLUECROSS BLUESHIELD OF TENNESSEE
TNA96927Medicare UPIN