Provider Demographics
NPI:1679903330
Name:BODENHAMER EYE CONSULTANTS, LLC
Entity type:Organization
Organization Name:BODENHAMER EYE CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:B
Authorized Official - Last Name:BODENHAMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-635-2020
Mailing Address - Street 1:3238 W TRUMAN BLVD
Mailing Address - Street 2:UPPER LEVEL
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5708
Mailing Address - Country:US
Mailing Address - Phone:573-635-2020
Mailing Address - Fax:573-635-7840
Practice Address - Street 1:3238 W TRUMAN BLVD
Practice Address - Street 2:UPPER LEVEL
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5708
Practice Address - Country:US
Practice Address - Phone:573-635-2020
Practice Address - Fax:573-635-7840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-17
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2261152WC0802X
MO2010026679152WC0802X
MO2007018327152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4822Medicare PIN
MO7077570001Medicare NSC
MODU6790Medicare PIN