Healthcare Provider Details

I. General information

NPI: 1205465929
Provider Name (Legal Business Name): MICHELLE MCGRAW BOISVERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMNAVSURFPAC 2841 RENDOVA RD
SAN DIEGO CA
92155-5490
US

IV. Provider business mailing address

COMNAVSURFPAC 2841 RENDOVA RD
SAN DIEGO CA
92155
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-9169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA205177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: