Provider Demographics
NPI:1346391505
Name:BOECKER, JOSEPH W (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:W
Last Name:BOECKER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3525 BUSBEE DR NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5677
Mailing Address - Country:US
Mailing Address - Phone:770-422-0064
Mailing Address - Fax:770-422-1765
Practice Address - Street 1:3525 BUSBEE DR NW
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5677
Practice Address - Country:US
Practice Address - Phone:770-422-0064
Practice Address - Fax:770-422-1765
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2015-11-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA13441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD28965Medicare UPIN
GA000078053FMedicaid