Basic Information
| Provider Information | |||||||||
| NPI: | 1588681191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODOR | ||||||||
| FirstName: | MARKO | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 BEARD RD | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945583442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072558825 | ||||||||
| FaxNumber: | 7072529325 | ||||||||
| Practice Location | |||||||||
| Address1: | 3421 VILLA LN | ||||||||
| Address2: | SUITE 2B | ||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072555454 | ||||||||
| FaxNumber: | 7072555411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | G63297 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 00G632970 | 05 | CA | MEDICAID |