Provider Demographics
NPI:1346534757
Name:BOSWELL, IRA KAEO (DO)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:KAEO
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:DO
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 678135
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8135
Mailing Address - Country:US
Mailing Address - Phone:469-818-0595
Mailing Address - Fax:
Practice Address - Street 1:5706 E MOCKINGBIRD LN STE 115-33
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-5460
Practice Address - Country:US
Practice Address - Phone:817-284-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3645208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation