Healthcare Provider Details

I. General information

NPI: 1497375232
Provider Name (Legal Business Name): KATHERINE BOEHM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 10/31/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 ALVARADO RD SUITE 2100
SAN DIEGO CA
92120
US

IV. Provider business mailing address

6699 ALVARADO RD SUITE 2100
SAN DIEGO CA
92120
US

V. Phone/Fax

Practice location:
  • Phone: 619-229-3909
  • Fax:
Mailing address:
  • Phone: 619-229-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A20113
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: