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General NPI Number Information
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NPI Number | 1275789711
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Entity Type | Organization
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Legal Business Name | JOHN BODEN MD LLC
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Dates
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Enumeration Date | 08/15/2008
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Last Update Date | 12/22/2008
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Provider Practice Location Address
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Address Line | 6879 US HIGHWAY 98 W
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459-3257
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Country | US
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Telephone | 850-502-1363
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Fax | 850-837-4837
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Provider Business Mailing Address
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Address Line | 42 INDIAN BAYOU DR
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City | DESTIN
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State | FL
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Zip | 32541-4447
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Country | US
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Telephone | 850-502-1363
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/PHYSICIAN
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Name | DR. JOHN M BODEN
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Credential | M.D.
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Telephone | 850-502-1363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME94719
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License Number State | FL
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