Provider Demographics
NPI:1225090772
Name:BOYSE, TEDRIC DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:TEDRIC
Middle Name:DALE
Last Name:BOYSE
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 1:114 WIND CHIME CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6433
Mailing Address - Country:US
Mailing Address - Phone:919-847-6431
Mailing Address - Fax:919-847-7005
Practice Address - Street 1:114 WIND CHIME CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6433
Practice Address - Country:US
Practice Address - Phone:919-847-6431
Practice Address - Fax:919-847-7005
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136WMMedicaid
NCH89640Medicare UPIN
NC89136WMMedicaid