Healthcare Provider Details

I. General information

NPI: 1437269487
Provider Name (Legal Business Name): MARK BRIAN BOAS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 W UWCHLAN AVE
EXTON PA
19341-1563
US

IV. Provider business mailing address

577 W UWCHLAN AVE
EXTON PA
19341-1563
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-2303
  • Fax:
Mailing address:
  • Phone: 610-363-2303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001120
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier428694
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 2
Identifier2814726
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCIGNA
# 3
Identifier51940
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA HMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: