Provider Demographics
NPI:1861586935
Name:BOEDEKER, EDGAR C (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:C
Last Name:BOEDEKER
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 1:1001 DR MARTIN LUTHER KING JR AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4713
Mailing Address - Country:US
Mailing Address - Phone:505-925-6000
Mailing Address - Fax:505-272-8018
Practice Address - Street 1:1001 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4713
Practice Address - Country:US
Practice Address - Phone:505-925-6000
Practice Address - Fax:505-272-8018
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0398207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO43351841Medicaid
AZ989444Medicaid
NM46554548Medicaid
NM46554548Medicaid
CO43351841Medicaid