Healthcare Provider Details

I. General information

NPI: 1518123421
Provider Name (Legal Business Name): KEVIN SCOTT BODKIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROADWAY
GARY IN
46408-4605
US

IV. Provider business mailing address

4900 BROADWAY
GARY IN
46408-4605
US

V. Phone/Fax

Practice location:
  • Phone: 419-696-6000
  • Fax: 419-696-6018
Mailing address:
  • Phone: 219-237-5170
  • Fax: 219-321-1931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34009615
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02005742A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: