Provider Demographics
NPI:1841286648
Name:BODNER, GARY ROY (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROY
Last Name:BODNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5515 POWERS RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-4295
Mailing Address - Country:US
Mailing Address - Phone:770-952-4945
Mailing Address - Fax:770-952-0320
Practice Address - Street 1:5515 POWERS RIDGE CT
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4295
Practice Address - Country:US
Practice Address - Phone:770-952-4945
Practice Address - Fax:770-952-0320
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2017-10-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA18205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000117686LMedicaid
GA000117686GMedicaid
GA000117686FMedicaid
GA000117686GMedicaid