Provider Demographics
NPI:1033430327
Name:EDWIN, MICAH BOAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:BOAZ
Last Name:EDWIN
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:PO BOX 4067
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33338-4067
Mailing Address - Country:US
Mailing Address - Phone:526-305-2802
Mailing Address - Fax:
Practice Address - Street 1:4850 W OAKLAND PARK BLVD STE 224
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7261
Practice Address - Country:US
Practice Address - Phone:786-214-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261987208D00000X
FLME143503208D00000X
NC2010-01073208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice