Healthcare Provider Details

I. General information

NPI: 1669430708
Provider Name (Legal Business Name): AIDA BODOUR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E MICHIGAN AVE
JACKSON MI
49202-3518
US

IV. Provider business mailing address

1400 E MICHIGAN AVE
JACKSON MI
49202-3518
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-4727
  • Fax: 517-784-1747
Mailing address:
  • Phone: 517-787-4727
  • Fax: 517-784-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301032967
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: