Provider Demographics
NPI:1316943970
Name:BODMAN, MYRON A (DPM)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:A
Last Name:BODMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21245 LORAIN RD
Mailing Address - Street 2:STE 115
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2140
Mailing Address - Country:US
Mailing Address - Phone:440-356-1989
Mailing Address - Fax:440-356-5944
Practice Address - Street 1:21245 LORAIN RD
Practice Address - Street 2:SUITE 115
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2140
Practice Address - Country:US
Practice Address - Phone:440-356-1989
Practice Address - Fax:440-356-5944
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH36-00-1747213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0360041Medicaid
OH4800325161OtherRAILROAD MEDICARE
OH6143640001Medicare NSC
OH0444215Medicare PIN
OHT80448Medicare UPIN