Provider Demographics
NPI:1144251810
Name:BODLAK, BRANDON KARL (DO)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:KARL
Last Name:BODLAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 W NEWBERRY RD STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2290
Mailing Address - Country:US
Mailing Address - Phone:352-372-7800
Mailing Address - Fax:352-372-7879
Practice Address - Street 1:4410 W NEWBERRY RD STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2290
Practice Address - Country:US
Practice Address - Phone:353-372-7800
Practice Address - Fax:352-372-7800
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSG081521OtherVISTA HEALTHPLAN
FL302712OtherAVMED
FL45751OtherBCBS
FL4664818OtherCIGNA
FL302712OtherAVMED
FLU81322Medicare ID - Type Unspecified