Provider Demographics
NPI:1093799702
Name:BOODIN, STEPHEN EARL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:EARL
Last Name:BOODIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:909 W MAPLE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1000
Mailing Address - Country:US
Mailing Address - Phone:248-288-3200
Mailing Address - Fax:248-288-0530
Practice Address - Street 1:909 W MAPLE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1000
Practice Address - Country:US
Practice Address - Phone:248-288-3200
Practice Address - Fax:248-288-0530
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2016-03-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI032164207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2950744Medicaid
MI2950744Medicaid
A76633Medicare UPIN