MEDICARE: JOHN BODEN MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME94719	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275789711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN BODEN MD LLC

Provider Business Mailing Address
First Line	:	42 INDIAN BAYOU DR
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-4447
Country	:	US
Telephone Number	:	850-502-1363
Fax Number	:

Provider Business Practice Location Address
First Line	:	6879 US HIGHWAY 98 W
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-3257
Country	:	US
Telephone Number	:	850-502-1363
Fax Number	:	850-837-4837

Authorized Official
Title or Position	:	PRESIDENT/PHYSICIAN
Name	:	DR. JOHN M BODEN
Credential	:	M.D.
Telephone Number	:	850-502-1363

Provider Enumeration Date	:	08/15/2008
Last Update Date	:	12/22/2008

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