Provider Demographics
NPI:1609830355
Name:BOULDEN, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:BOULDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12499 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8281
Mailing Address - Country:US
Mailing Address - Phone:515-440-2676
Mailing Address - Fax:515-440-2677
Practice Address - Street 1:12499 UNIVERSITY AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50325-8281
Practice Address - Country:US
Practice Address - Phone:515-440-2676
Practice Address - Fax:515-440-2677
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19337207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
50215OtherBLUE CROSS BLUE SHIELD
IA2138891Medicaid
IAP00060888OtherRAILROAD MEDICARE
50215OtherBLUE CROSS BLUE SHIELD
IA2138891Medicaid
IA4947140001Medicare NSC