=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831192095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEBRA R. BOENDER, DPM, PHD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 06/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26553 MARINERS RD
-----------------------------------------------------
City | CRISFIELD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21817-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-465-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26553 MARINERS RD
-----------------------------------------------------
City | CRISFIELD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21817-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-465-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PRACTITIONER/PROPRIETOR
-----------------------------------------------------
Name | DR. DEBRA R BOENDER
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 410-465-4410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 01409
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------