Provider Demographics
NPI:1235143512
Name:BOAKE, GREGORY W (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:BOAKE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-0330
Mailing Address - Country:US
Mailing Address - Phone:317-863-2556
Mailing Address - Fax:317-203-0420
Practice Address - Street 1:10122 E 10TH ST STE 230
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2664
Practice Address - Country:US
Practice Address - Phone:317-355-7356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN070001028A213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
5324290008OtherDME FC
IN070001028AOtherPODIATRIST LICENSE
5324290003OtherDME ES
5324290004OtherDME BR
5324290006OtherDME MC
5324290005OtherDME AC
IN20087023Medicaid
5324290007OtherDME WV
IN20087023Medicaid
5324290006OtherDME MC