Provider Demographics
NPI:1871729962
Name:BODTKE, SUSAN K (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:BODTKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1407
Mailing Address - Country:US
Mailing Address - Phone:619-688-1600
Mailing Address - Fax:619-688-3099
Practice Address - Street 1:4311 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1407
Practice Address - Country:US
Practice Address - Phone:619-688-1600
Practice Address - Fax:619-688-3099
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG88460207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine