Healthcare Provider Details

I. General information

NPI: 1275562944
Provider Name (Legal Business Name): LARS BOMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BROAD ST #801
BOSTON MA
02109-3803
US

IV. Provider business mailing address

15 BROAD ST #801
BOSTON MA
02109-3803
US

V. Phone/Fax

Practice location:
  • Phone: 857-239-9120
  • Fax: 857-277-1355
Mailing address:
  • Phone: 857-239-9120
  • Fax: 857-277-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number60137
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: