Basic Information
| Provider Information | |||||||||
| NPI: | 1932195476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODWIN | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 279 IMPERIAL HWY | ||||||||
| Address2: | SUITE 730 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928351041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494841 | ||||||||
| FaxNumber: | 7144494956 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E VALENCIA MESA DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928353813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144465640 | ||||||||
| FaxNumber: | 7144465625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 04/26/2013 | ||||||||
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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 | 207R00000X | G46166 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | G46166 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.