Healthcare Provider Details

I. General information

NPI: 1386041903
Provider Name (Legal Business Name): IMRE BODO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 PEACHTREE DUNWOODY RD SUITE 150
ATLANTA GA
30342-1764
US

IV. Provider business mailing address

5665 PEACHTREE DUNWOODY RD SUITE 150
ATLANTA GA
30342-1764
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1900
  • Fax:
Mailing address:
  • Phone: 404-778-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number73081
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: