Provider Demographics
NPI:1730141615
Name:BODEN, ERIC S (PT, MPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:BODEN
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-2268
Mailing Address - Country:US
Mailing Address - Phone:917-750-4579
Mailing Address - Fax:
Practice Address - Street 1:1608 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-2268
Practice Address - Country:US
Practice Address - Phone:917-750-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021876225100000X
NJ40QA00918000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ043104Medicare ID - Type Unspecified