Healthcare Provider Details

I. General information

NPI: 1114997418
Provider Name (Legal Business Name): JOHN HEBER BODEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

2108 E THOMAS RD STE 130
PHOENIX AZ
85016-0008
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-1000
  • Fax:
Mailing address:
  • Phone: 602-933-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number32434
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23537
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number68744
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: