Basic Information
| Provider Information | |||||||||
| NPI: | 1467486118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODOR | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 W. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | HOPKINTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084355506 | ||||||||
| FaxNumber: | 5084975079 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 W. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | HOPKINTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084355506 | ||||||||
| FaxNumber: | 5084975079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/28/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 212971 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | J24759 | 01 | MA | BLUE CROSS/BLUE SHIELD | OTHER | 2942274 | 01 | MA | AETNA/US HEALTHCARE | OTHER | 2942274 | 01 | MA | AETNA | OTHER | 204597 | 01 | MA | HARVARD PILGRIM | OTHER | 461234 | 01 | MA | TUFTS | OTHER | 0192970 | 05 | MA | MEDICAID | 198177 | 01 | MA | HEALTHSOURCE(CMHC) | OTHER | 6079812001 | 01 | MA | CIGNA | OTHER |