Provider Demographics
NPI:1982746616
Name:BODKER, ALIISA (OD)
Entity Type:Individual
Prefix:DR
First Name:ALIISA
Middle Name:
Last Name:BODKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N. RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6601
Mailing Address - Country:US
Mailing Address - Phone:734-725-2020
Mailing Address - Fax:734-725-2040
Practice Address - Street 1:108 N. RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-6601
Practice Address - Country:US
Practice Address - Phone:734-725-2020
Practice Address - Fax:734-725-2040
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN26930157Medicare PIN