Basic Information
| Provider Information | |||||||||
| NPI: | 1518351410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODEPUDI | ||||||||
| FirstName: | HAREN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9033 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349959033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232832 | ||||||||
| FaxNumber: | 7727812716 | ||||||||
| Practice Location | |||||||||
| Address1: | 10050 SW INNOVATION WAY STE 102 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349872117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723443811 | ||||||||
| FaxNumber: | 7723443890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2015 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | ME145133 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 106666500 | 05 | FL | MEDICAID |