Provider Demographics
NPI:1134651250
Name:BODEN, BRIAN EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:BODEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MEETING HOUSE LANE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968
Mailing Address - Country:US
Mailing Address - Phone:631-726-8200
Mailing Address - Fax:
Practice Address - Street 1:1200 OLD YORK RD STE 2B
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3720
Practice Address - Country:US
Practice Address - Phone:215-481-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304138207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine