MEDICARE: DR. ROBERT MARK BODENHAMER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	12800	OK
2	208600000X	Surgery Physician	12800	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	020047750	OTHER	OK	RRMDR

General Provider Information

NPI Number	:	1366436693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT MARK BODENHAMER M.D.

Provider Business Mailing Address
First Line	:	7800 NW 85TH TER
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-3385
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4050 W MEMORIAL RD FL 3
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-8382
Country	:	US
Telephone Number	:	405-608-3800
Fax Number	:	405-608-4768

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	06/06/2022

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