Provider Demographics
NPI:1386725463
Name:BODOR, RICHARD MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:BODOR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3350 LA JOLLA VILLAGE DR
Mailing Address - Street 2:SECTION OF VA PLASTIC SURGERY, MAIL CODE 112K
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0001
Mailing Address - Country:US
Mailing Address - Phone:858-642-3808
Mailing Address - Fax:858-552-7530
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:SECTION OF VA PLASTIC SURGERY, MAIL CODE 112K
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0001
Practice Address - Country:US
Practice Address - Phone:858-642-3808
Practice Address - Fax:858-552-7530
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2010-01-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA053083208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG22219Medicare UPIN