Basic Information
| Provider Information | |||||||||
| NPI: | 1578597175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODNER | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168445661 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35-044291 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000000025982 | 01 | OH | ANTHEM | OTHER | 000000216802 | 01 | OH | UNISON | OTHER | 639506 | 01 | OH | AETNA | OTHER | 000000507513 | 01 | OH | ANTHEM | OTHER | 0441963 | 05 | OH | MEDICAID | 363367 | 01 | OH | WELLCARE | OTHER | P00364270 | 01 | OH | RAILROAD MEDICARE | OTHER | 0639506 | 01 | OH | AETNA | OTHER | 1900369 | 01 | OH | UHC | OTHER | 741846 | 01 | OH | BUCKEYE | OTHER |