Provider Demographics
NPI:1073549879
Name:BOUSHKA, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:BOUSHKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3850 FOOTHILLS RD
Mailing Address - Street 2:STE 9
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4632
Mailing Address - Country:US
Mailing Address - Phone:505-532-8800
Mailing Address - Fax:505-532-5920
Practice Address - Street 1:6065 MONTANA AVE
Practice Address - Street 2:BLDG A STE 6
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1835
Practice Address - Country:US
Practice Address - Phone:915-881-1900
Practice Address - Fax:915-771-9345
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ07502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86491RMedicare ID - Type UnspecifiedMEDICARE -TEXAS
H09636Medicare UPIN