Provider Demographics
NPI:1154312858
Name:BOESEL, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:BOESEL
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 1:13965 N. 75TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-6097
Mailing Address - Country:US
Mailing Address - Phone:602-843-2991
Mailing Address - Fax:602-978-1226
Practice Address - Street 1:13965 N. 75TH AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-6097
Practice Address - Country:US
Practice Address - Phone:602-843-2991
Practice Address - Fax:602-978-1226
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31125207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
74965Medicare ID - Type Unspecified
74965Medicare UPIN