Healthcare Provider Details

I. General information

NPI: 1770534372
Provider Name (Legal Business Name): GEOFFREY R BODEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6608 KENNEY PL
EDINA MN
55439-1427
US

IV. Provider business mailing address

6608 KENNEY PL
EDINA MN
55439-1427
US

V. Phone/Fax

Practice location:
  • Phone: 952-947-9445
  • Fax:
Mailing address:
  • Phone: 952-947-9445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number29842
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: