Provider Demographics
NPI:1043203318
Name:BOUDER, T. GLEN (MD)
Entity type:Individual
Prefix:
First Name:T.
Middle Name:GLEN
Last Name:BOUDER
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 1:220 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2896
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:1840 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2808
Practice Address - Country:US
Practice Address - Phone:540-536-8874
Practice Address - Fax:540-536-7847
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051542L207RP1001X
VA0101244705207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1043203318Medicaid
VA00Y116W02Medicare PIN
MD1043203318Medicaid
PA044609Medicare PIN