Healthcare Provider Details

I. General information

NPI: 1154309375
Provider Name (Legal Business Name): JAMES JOSEPH BOEHMKE JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 MOORES LN STE A
TEXARKANA TX
75503-4660
US

IV. Provider business mailing address

1920 MOORES LN STE A
TEXARKANA TX
75503-4660
US

V. Phone/Fax

Practice location:
  • Phone: 903-792-8030
  • Fax: 903-793-0844
Mailing address:
  • Phone: 903-792-8030
  • Fax: 903-793-0844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0102201412
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: