Provider Demographics
NPI:1932195476
Name:BODWIN, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:279 IMPERIAL HWY
Mailing Address - Street 2:SUITE 730
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1041
Mailing Address - Country:US
Mailing Address - Phone:714-449-4841
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:100 E VALENCIA MESA DR
Practice Address - Street 2:SUITE 105
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3813
Practice Address - Country:US
Practice Address - Phone:714-446-5640
Practice Address - Fax:714-446-5625
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46166207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG46166FMedicare PIN
CAA50310Medicare UPIN