Provider Demographics
NPI:1548441652
Name:BODE, LAURA JEAN (RT(T),CMD,BS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:BODE
Suffix:
Gender:F
Credentials:RT(T),CMD,BS
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:FORTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3610 FOSSIL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-4650
Mailing Address - Country:US
Mailing Address - Phone:618-210-1179
Mailing Address - Fax:
Practice Address - Street 1:4921 PARK VIEW PLACE
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:618-210-1179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation Therapy
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other