Basic Information
| Provider Information | |||||||||
| NPI: | 1699788943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODOR | ||||||||
| FirstName: | GEZA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1055 CLERMONT ST | ||||||||
| Address2: | LAB 113 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033998020 | ||||||||
| FaxNumber: | 3033934176 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 CLERMONT ST | ||||||||
| Address2: | LAB 113 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033998020 | ||||||||
| FaxNumber: | 3033934176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 01/02/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZH0000X | 35920 | CO | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0105X | 35920 | CO | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0104X | 35920 | CO | N | Allopathic & Osteopathic Physicians | Pathology | Chemical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 47639369 | 05 | CO | MEDICAID |