Healthcare Provider Details

I. General information

NPI: 1417989781
Provider Name (Legal Business Name): CHARLES E BOYD JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E WOODS DR
LITITZ PA
17543-9253
US

IV. Provider business mailing address

2461 SANTA MONICA BLVD SUITE 108
SANTA MONICA CA
90404-2138
US

V. Phone/Fax

Practice location:
  • Phone: 717-823-6125
  • Fax:
Mailing address:
  • Phone: 866-487-7621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD072807L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier001833251
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
IdentifierB04234402
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerMEDICARE PTAN #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: