Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC003210L | PA |
NPI | 1245341130 |
---|---|
Provider Name | Dr. Paul Brown Bodhise |
First Address | Philadelphia, PA 19147-1901 |
Second Address | Philadelphia, PA 19147-1901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0061133000 | (02) | PA |