Provider Demographics
NPI:1083690614
Name:BOEHNERT, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:BOEHNERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-421-8888
Mailing Address - Fax:617-421-8733
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:PEDIATRICS DEPT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-8888
Practice Address - Fax:617-421-8733
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA53723208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3191231Medicaid
MAPP319OtherHARVARD PILGRIM
MA0015141OtherNEIGHBORHOOD HEALTH
MA053723OtherTUFTS
MAJ10683OtherBLUE CROSS
MAE73519Medicare UPIN
MAJ10683Medicare ID - Type Unspecified