Provider Demographics
NPI:1376518217
Name:BOUMAN, JERRY CRAIG (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:CRAIG
Last Name:BOUMAN
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 1:1902 S US HIGHWAY 59 BLDG D
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-4955
Mailing Address - Country:US
Mailing Address - Phone:620-423-1606
Mailing Address - Fax:620-423-1668
Practice Address - Street 1:1902 S US HIGHWAY 59 BLDG D
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357-4955
Practice Address - Country:US
Practice Address - Phone:620-423-1606
Practice Address - Fax:620-423-1668
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2996208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF32432Medicare UPIN