Provider Demographics
NPI:1174531933
Name:BODILY, KALE D (MD)
Entity type:Individual
Prefix:
First Name:KALE
Middle Name:D
Last Name:BODILY
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 1:1608 N STOCKTON HILL RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4141
Mailing Address - Country:US
Mailing Address - Phone:928-718-0180
Mailing Address - Fax:
Practice Address - Street 1:1608 N STOCKTON HILL RD
Practice Address - Street 2:SUITE 104
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4141
Practice Address - Country:US
Practice Address - Phone:928-718-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN488462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN066608000Medicaid
MN300003994Medicare ID - Type Unspecified
MN300005458Medicare PIN
I59782Medicare UPIN