Provider Demographics
NPI:1538212261
Name:BOEHNING, STEPHEN ODELL
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ODELL
Last Name:BOEHNING
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 1:2340 W BELL RD STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-3206
Mailing Address - Country:US
Mailing Address - Phone:602-298-1822
Mailing Address - Fax:602-298-1823
Practice Address - Street 1:2340 W BELL RD STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-3206
Practice Address - Country:US
Practice Address - Phone:602-298-1822
Practice Address - Fax:602-298-1823
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20-4025903174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4153650001Medicare NSC