Healthcare Provider Details

I. General information

NPI: 1689669640
Provider Name (Legal Business Name): MICHAEL J BODE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S GREEN ST SUITE 130
BROWNSBURG IN
46112-2049
US

IV. Provider business mailing address

1100 SOUTHFIELD DR SUITE 1370
PLAINFIELD IN
46168-4498
US

V. Phone/Fax

Practice location:
  • Phone: 317-858-4610
  • Fax: 317-858-4620
Mailing address:
  • Phone: 317-837-5571
  • Fax: 317-837-5580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01044134A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: