Provider Demographics
NPI:1780600312
Name:BODILY, KURT O (MD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:O
Last Name:BODILY
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 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W STE 100
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-1268
Practice Address - Fax:801-812-5454
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT322494-1205207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
100009090OtherPALMETTO
UT265465OtherDMBA
UT870281028BO2OtherEMIA
UT39508OtherPEHP
UTQM0000009163OtherALTIUS
UT107007621101OtherIHC
UT29-00038OtherUNITED HEALTHCARE
UT870281028000Medicaid