Healthcare Provider Details

I. General information

NPI: 1063133635
Provider Name (Legal Business Name): JACOB BODWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 S MIAMI AVE
MIAMI FL
33133-4253
US

IV. Provider business mailing address

770 CLAUGHTON ISLAND DR APT 810
MIAMI FL
33131-2627
US

V. Phone/Fax

Practice location:
  • Phone: 305-854-4400
  • Fax:
Mailing address:
  • Phone: 952-239-1766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: