Provider Demographics
NPI:1053365528
Name:BODELL, LEONARD (MD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:BODELL
Suffix:
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:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-406-3860
Mailing Address - Fax:602-406-6132
Practice Address - Street 1:370 E VIRGINIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1254
Practice Address - Country:US
Practice Address - Phone:602-258-4788
Practice Address - Fax:602-258-5131
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9925207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ214445Medicaid
AZZ130319Medicare PIN