Healthcare Provider Details

I. General information

NPI: 1629056155
Provider Name (Legal Business Name): MICHAEL JAMES BOQUARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 HAWKINS POINT RD MAILSTOP 28B
BALTIMORE MD
21226-1797
US

IV. Provider business mailing address

1118 S HIGHLAND AVE
BALTIMORE MD
21224-5109
US

V. Phone/Fax

Practice location:
  • Phone: 410-636-7506
  • Fax: 410-636-7868
Mailing address:
  • Phone: 443-474-1517
  • Fax: 410-636-7868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number157258
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: