Provider Demographics
NPI:1487699104
Name:BODEN, THOMAS MICHAEL (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:BODEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:MICHAEL
Other - Last Name:KERSTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1242
Mailing Address - Fax:952-942-3361
Practice Address - Street 1:313 TRIQ TA'TAHT
Practice Address - Street 2:L-IRDUM STA. MARIA EST.
Practice Address - City:MELLIEHA
Practice Address - State:NOT APPLICABLE
Practice Address - Zip Code:MLH 2747
Practice Address - Country:MT
Practice Address - Phone:952-595-1242
Practice Address - Fax:952-942-3361
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN465262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H74260Medicare UPIN