Provider Demographics
NPI:1245227800
Name:BOEHME, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:BOEHME
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:PO BOX 17809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7809
Mailing Address - Country:US
Mailing Address - Phone:904-249-4456
Mailing Address - Fax:904-249-7703
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:STE-170A
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3233
Practice Address - Country:US
Practice Address - Phone:904-249-4456
Practice Address - Fax:904-249-7703
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME625332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00240372OtherRAILROAD MEDICARE
FL372291100Medicaid
FL212248OtherAVMED
FL18695OtherFLORIDA BCBS
FLP00647889OtherRAILROAD MEDICARE
FLP00240372OtherRAILROAD MEDICARE
FL212248OtherAVMED
OKOKAAA2745Medicare PIN
FLF42036Medicare UPIN
FLP00647889OtherRAILROAD MEDICARE