Provider Demographics
NPI:1669039822
Name:BOEDER, DANIEL THEODORE
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THEODORE
Last Name:BOEDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19642
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9642
Mailing Address - Country:US
Mailing Address - Phone:217-656-8229
Mailing Address - Fax:217-585-6893
Practice Address - Street 1:319 E MADISON ST FL 3
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1035
Practice Address - Country:US
Practice Address - Phone:217-545-6900
Practice Address - Fax:217-585-6893
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.0739802084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry