Provider Demographics
NPI:1275562944
Name:BOMAN, LARS (MD)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:
Last Name:BOMAN
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 1:15 BROAD ST
Mailing Address - Street 2:#801
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-3803
Mailing Address - Country:US
Mailing Address - Phone:857-239-9120
Mailing Address - Fax:857-277-1355
Practice Address - Street 1:15 BROAD ST
Practice Address - Street 2:#801
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-3803
Practice Address - Country:US
Practice Address - Phone:857-239-9120
Practice Address - Fax:857-277-1355
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA601372083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI004624OtherBLUECHIP
MAJ07574OtherBLUECROSS BLUECHIELD OF M
MA3037886Medicaid
MA42894OtherCHILDRENS MEDICAL SECURI
MA8269OtherHARVARD PILGRIM
MA00028554OtherBOSTON HEALTH NET
MA1701023Other1701023
RI4339-7OtherBLUECROSS RI
MA6351OtherNEIGHBORHOOD HEALTH PLAN
MA89755OtherUS HEALTHCARE
MA125141400OtherACS/WORKERS COMP
MA754146OtherTUFTS
MA8269OtherHARVARD PILGRIM
MA3037886Medicaid