Provider Demographics
NPI:1073623229
Name:BOESE, DIANE RENE (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:RENE
Last Name:BOESE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07062-2038
Mailing Address - Country:US
Mailing Address - Phone:908-757-5697
Mailing Address - Fax:
Practice Address - Street 1:301 MOUNT HOPE AVE
Practice Address - Street 2:SUITE 2001
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-2130
Practice Address - Country:US
Practice Address - Phone:973-366-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27TO00128800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJV02357Medicare UPIN