MEDICARE: DR. DIANE RENE BOESE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	27TO00128800	NJ

General Provider Information

NPI Number	:	1073623229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE RENE BOESE O.D.

Provider Business Mailing Address
First Line	:	776 RAVINE RD
Second Line	:
City	:	PLAINFIELD
State	:	NJ
Zip	:	07062-2038
Country	:	US
Telephone Number	:	908-757-5697
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 MOUNT HOPE AVE
Second Line	:	SUITE 2001
City	:	ROCKAWAY
State	:	NJ
Zip	:	07866-2130
Country	:	US
Telephone Number	:	973-366-9622
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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