Provider Demographics
NPI:1841458973
Name:BODDIE, NATHAN K (MD, MS)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:K
Last Name:BODDIE
Suffix:
Gender:M
Credentials:MD, MS
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Mailing Address - Street 1:375 NW BEAVER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1802
Mailing Address - Country:US
Mailing Address - Phone:541-447-0707
Mailing Address - Fax:
Practice Address - Street 1:2965 NE CONNERS AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7753
Practice Address - Country:US
Practice Address - Phone:541-323-4268
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD 60018386207R00000X
ORMD28592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500600848Medicaid
ORR182625Medicare PIN