Provider Demographics
NPI:1003819459
Name:BOERNER, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:BOERNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W MAIN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7308
Mailing Address - Country:US
Mailing Address - Phone:208-344-3220
Mailing Address - Fax:208-344-0461
Practice Address - Street 1:111 W MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7308
Practice Address - Country:US
Practice Address - Phone:208-344-3220
Practice Address - Fax:208-344-0461
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2020-04-15
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
IDM7206207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID180038677OtherRAILROAD MEDICARE
ID804243800Medicaid
IDJ5164OtherBLUE CROSS
ID000010002554OtherREGENCE BLUE SHIELD
ID1317920001OtherDMERC
ID1137262Medicare PIN
IDF36656Medicare UPIN
IDJ5164OtherBLUE CROSS