Healthcare Provider Details

I. General information

NPI: 1760927990
Provider Name (Legal Business Name): EMILY BOOZALIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2016
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-6457
US

IV. Provider business mailing address

1618 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-6457
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-3376
  • Fax: 208-884-0858
Mailing address:
  • Phone: 208-884-3376
  • Fax: 208-884-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM17000
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: