Provider Demographics
NPI:1932167400
Name:BODEN, ELISA K (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:K
Last Name:BODEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-4373
Mailing Address - Fax:503-418-4189
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:BUCK PAVILLION 3RD FLOOR
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-2319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226232207R00000X
WAMD 60229173207RG0100X
NY60 256098207RG0100X
ORMD201931207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1932167400OtherMONTANA DSHS
WA0284291OtherDEPT. OF LABOR AND INDUSTRIES
WA1932167400Medicaid
WA1932167400OtherMONTANA DSHS
WA1932167400Medicaid