Healthcare Provider Details

I. General information

NPI: 1841225059
Provider Name (Legal Business Name): OTTO ROBERT BOEHM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 E 7TH ST SUITE 100
CHARLOTTE NC
28204-4319
US

IV. Provider business mailing address

2630 E 7TH ST SUITE 100
CHARLOTTE NC
28204-4319
US

V. Phone/Fax

Practice location:
  • Phone: 704-372-7900
  • Fax: 704-376-2216
Mailing address:
  • Phone: 704-372-7900
  • Fax: 704-376-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number21627
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: