Basic Information
| Provider Information | |||||||||
| NPI: | 1619986833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ELDEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9480 BRIAR VILLAGE PT | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192783627 | ||||||||
| FaxNumber: | 7196232101 | ||||||||
| Practice Location | |||||||||
| Address1: | 9480 BRIAR VILLAGE PT | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192783627 | ||||||||
| FaxNumber: | 7196232101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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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 | 207Q00000X | 37981 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 98172549 | 05 | CO | MEDICAID |