Provider Demographics
NPI:1164484721
Name:BOARDMAN, JOHN WORKS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WORKS
Last Name:BOARDMAN
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 1:22100 BOTHELL EVERETT HWY
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8431
Mailing Address - Country:US
Mailing Address - Phone:208-416-2932
Mailing Address - Fax:855-673-9190
Practice Address - Street 1:1110 CHAPIN ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6472
Practice Address - Country:US
Practice Address - Phone:608-362-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012354542085R0202X
WI36892-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAH30684Medicare UPIN