Healthcare Provider Details

I. General information

NPI: 1770544736
Provider Name (Legal Business Name): STEVEN D BOEKE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 HOME PLZ
WATERLOO IA
50701-4822
US

IV. Provider business mailing address

999 HOME PLZ
WATERLOO IA
50701-4822
US

V. Phone/Fax

Practice location:
  • Phone: 319-236-0815
  • Fax: 319-234-0847
Mailing address:
  • Phone: 319-236-0815
  • Fax: 319-234-0847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1634
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: