Healthcare Provider Details

I. General information

NPI: 1134051055
Provider Name (Legal Business Name): DR. DAVID BOEHNKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 PEBBLE BEACH DR
CLARK SD
57225-1152
US

IV. Provider business mailing address

1017 PEBBLE BEACH DR
CLARK SD
57225-1152
US

V. Phone/Fax

Practice location:
  • Phone: 201-285-7865
  • Fax: 206-750-9006
Mailing address:
  • Phone: 201-285-7865
  • Fax: 206-750-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number10288292
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: