Healthcare Provider Details

I. General information

NPI: 1871729962
Provider Name (Legal Business Name): SUSAN K BODTKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 3RD AVE
SAN DIEGO CA
92103-1407
US

IV. Provider business mailing address

4311 3RD AVE
SAN DIEGO CA
92103-1407
US

V. Phone/Fax

Practice location:
  • Phone: 619-688-1600
  • Fax: 619-688-3099
Mailing address:
  • Phone: 619-688-1600
  • Fax: 619-688-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG88460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: