MEDICARE: W.P. BOORAS, M.D., P.A.

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	207Q00000X	Family Medicine Physician	ME0040719	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080025632	OTHER	GA	PALMETTO GBA - RAILROAD
2	15776	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1437221033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W.P. BOORAS, M.D., P.A.

Provider Business Mailing Address
First Line	:	1922 UNIVERSITY BLVD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8933
Country	:	US
Telephone Number	:	904-721-7844
Fax Number	:	904-727-3597

Provider Business Practice Location Address
First Line	:	1922 UNIVERSITY BLVD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8933
Country	:	US
Telephone Number	:	904-721-7844
Fax Number	:	904-727-3597

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES H BOORAS
Credential	:	M.D.
Telephone Number	:	904-721-7844

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/02/2008

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