Provider Demographics
NPI:1215937610
Name:BODISON, DAN ROBERT JR (MD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:ROBERT
Last Name:BODISON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MONTICELLO RD
Mailing Address - Street 2:EAU CLAIRE COOPERATIVE HEALTH CENTER
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-4156
Mailing Address - Country:US
Mailing Address - Phone:803-252-7001
Mailing Address - Fax:803-252-5219
Practice Address - Street 1:4605 MONTICELLO RD
Practice Address - Street 2:EAU CLAIRE COOPERATIVE HEALTH CENTER
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4156
Practice Address - Country:US
Practice Address - Phone:803-252-7001
Practice Address - Fax:803-252-5219
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC119134Medicaid