Healthcare Provider Details

I. General information

NPI: 1245227800
Provider Name (Legal Business Name): RICHARD J BOEHME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 13TH AVE S STE-170A
JACKSONVILLE BEACH FL
32250-3233
US

IV. Provider business mailing address

PO BOX 17809
JACKSONVILLE FL
32245-7809
US

V. Phone/Fax

Practice location:
  • Phone: 904-249-4456
  • Fax: 904-249-7703
Mailing address:
  • Phone: 904-249-4456
  • Fax: 904-249-7703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME62533
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: