Healthcare Provider Details

I. General information

NPI: 1609457969
Provider Name (Legal Business Name): JASON BOEHMER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR RM 2115
YPSILANTI MI
48197-1097
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1181202
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: