Provider Demographics
NPI:1831192095
Name:DEBRA R. BOENDER, DPM, PHD, LLC
Entity type:Organization
Organization Name:DEBRA R. BOENDER, DPM, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PRACTITIONER/PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-465-4410
Mailing Address - Street 1:26553 MARINERS RD
Mailing Address - Street 2:
Mailing Address - City:CRISFIELD
Mailing Address - State:MD
Mailing Address - Zip Code:21817-2109
Mailing Address - Country:US
Mailing Address - Phone:410-465-4410
Mailing Address - Fax:
Practice Address - Street 1:26553 MARINERS RD
Practice Address - Street 2:
Practice Address - City:CRISFIELD
Practice Address - State:MD
Practice Address - Zip Code:21817-2109
Practice Address - Country:US
Practice Address - Phone:410-465-4410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01409213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002485895002OtherUNITED HEALTHCARE
MD002216100Medicaid
MD01409OtherMARYLAND STATE LICENSE
MDDC9138OtherRAILROAD MEDICARE
MD606937400OtherFED WORKERS COMP/DOL
MD689BP0/64490301OtherCAREFIRST BC/BS NASCO
MDK4150001OtherCAREFIRST FED AND DC AREA
MD2137828OtherONE NET
MD=========OtherCARE IMPROVEMENT PLUS
MD01409OtherMARYLAND STATE LICENSE
MD002216100Medicaid
DCG02100Medicare PIN
MD01409OtherMARYLAND STATE LICENSE
MD606937400OtherFED WORKERS COMP/DOL
MD689BP0/64490301OtherCAREFIRST BC/BS NASCO