Healthcare Provider Details

I. General information

NPI: 1669039822
Provider Name (Legal Business Name): DR. DANIEL THEODORE BOEDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 BROADWAY ST
QUINCY IL
62301-2719
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-224-4453
  • Fax: 217-224-9383
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-277-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2025030304
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036168173
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036168173
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2025030304
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: