Provider Demographics
NPI:1164544466
Name:EDWARD N. BODURIAN, M.D., P.A.
Entity Type:Organization
Organization Name:EDWARD N. BODURIAN, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-656-4064
Mailing Address - Street 1:5530 WISCONSIN AVE
Mailing Address - Street 2:SUITE 515
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-4404
Mailing Address - Country:US
Mailing Address - Phone:301-656-4064
Mailing Address - Fax:301-657-9561
Practice Address - Street 1:5530 WISCONSIN AVE
Practice Address - Street 2:SUITE 515
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4404
Practice Address - Country:US
Practice Address - Phone:301-656-4064
Practice Address - Fax:301-657-9561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA575OtherCAREFIRST BLUE CROSS BLUE SHIELD
MDCD9109OtherRAILROAD MEDICARE
MD32331400Medicaid
DC445870Medicaid
MD32331400Medicaid