Provider Demographics
NPI:1992717565
Name:BOUDRO, STEPHEN WILLIAM (DC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WILLIAM
Last Name:BOUDRO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 W BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5037
Mailing Address - Country:US
Mailing Address - Phone:630-617-5444
Mailing Address - Fax:
Practice Address - Street 1:287 W BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5037
Practice Address - Country:US
Practice Address - Phone:630-617-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001682440OtherBLUE CROSS BLUE SHIELD
IL0001682440OtherBLUE CROSS BLUE SHIELD