Healthcare Provider Details

I. General information

NPI: 1881988368
Provider Name (Legal Business Name): NIA I BODRICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 MINNESOTA AVE NE
WASHINGTON DC
20019-2661
US

IV. Provider business mailing address

3924 MINNESOTA AVE NE
WASHINGTON DC
20019-2661
US

V. Phone/Fax

Practice location:
  • Phone: 202-398-8683
  • Fax: 202-388-4014
Mailing address:
  • Phone: 202-398-8683
  • Fax: 202-388-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD042461
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: