Provider Demographics
NPI:1720037310
Name:BODEN, MILTON DERRICK (MD)
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:DERRICK
Last Name:BODEN
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 1:2101 CHESTERFIELD DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3705
Mailing Address - Country:US
Mailing Address - Phone:404-633-1945
Mailing Address - Fax:404-297-5008
Practice Address - Street 1:2665 N DECATUR RD
Practice Address - Street 2:SUITE 330
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6149
Practice Address - Country:US
Practice Address - Phone:404-297-9755
Practice Address - Fax:404-297-5008
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041518207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG36909Medicare UPIN
GA44ZCBHDMedicare ID - Type Unspecified