Provider Demographics
NPI:1801882006
Name:BODMER, EDWARD JAMES (DPM)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:BODMER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6499 S KINGS RANCH RD
Mailing Address - Street 2:STE 6
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-2920
Mailing Address - Country:US
Mailing Address - Phone:480-982-8137
Mailing Address - Fax:480-983-8153
Practice Address - Street 1:9765 E DEAD SURE PL
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85218-7176
Practice Address - Country:US
Practice Address - Phone:480-363-3066
Practice Address - Fax:480-983-8153
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0152213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ118594OtherMEDICARE GROUP
AZ118594OtherMEDICARE GROUP
AZ118701Medicare PIN