Provider Demographics
NPI:1588105597
Name:BODDICKER, BRETT
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:
Last Name:BODDICKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1902
Mailing Address - Country:US
Mailing Address - Phone:319-213-5124
Mailing Address - Fax:
Practice Address - Street 1:812 UNIVERSITY STREET
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219
Practice Address - Country:US
Practice Address - Phone:319-213-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3727390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program