Healthcare Provider Details

I. General information

NPI: 1750382040
Provider Name (Legal Business Name): DAVID C BOARDMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 16TH ST
BEDFORD IN
47421-3510
US

IV. Provider business mailing address

PO BOX 1149
BLOOMINGTON IN
47402-1149
US

V. Phone/Fax

Practice location:
  • Phone: 812-278-8800
  • Fax: 812-275-1343
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2002006268
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02004902A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: