Healthcare Provider Details

I. General information

NPI: 1396717567
Provider Name (Legal Business Name): DONALD T BODEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 9TH ST SE
ROCHESTER MN
55904-6756
US

IV. Provider business mailing address

210 9TH ST SE
ROCHESTER MN
55904-6756
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-3443
  • Fax:
Mailing address:
  • Phone: 507-288-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number32556
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number31662
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: