Healthcare Provider Details

I. General information

NPI: 1306568928
Provider Name (Legal Business Name): STEPHEN BODDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

IV. Provider business mailing address

14106 SW 62ND ST
MIAMI FL
33183-1919
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: