Healthcare Provider Details

I. General information

NPI: 1609912146
Provider Name (Legal Business Name): PAUL CHRISTOPHER BOULWARE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16620 N 40TH ST STE E-1
PHOENIX AZ
85032-3348
US

IV. Provider business mailing address

16620 N 40TH ST STE E1
PHOENIX AZ
85032-3357
US

V. Phone/Fax

Practice location:
  • Phone: 602-464-9576
  • Fax: 602-626-8901
Mailing address:
  • Phone: 602-464-9576
  • Fax: 480-428-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number41726
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: