Healthcare Provider Details

I. General information

NPI: 1316943970
Provider Name (Legal Business Name): MYRON A BODMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21245 LORAIN RD SUITE 115
FAIRVIEW PARK OH
44126-2140
US

IV. Provider business mailing address

21245 LORAIN RD STE 115
FAIRVIEW PARK OH
44126-2140
US

V. Phone/Fax

Practice location:
  • Phone: 440-356-1989
  • Fax: 440-356-5944
Mailing address:
  • Phone: 440-356-1989
  • Fax: 440-356-5944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number36-00-1747
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: