Provider Demographics
NPI:1437221033
Name:W.P. BOORAS, M.D., P.A.
Entity Type:Organization
Organization Name:W.P. BOORAS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOORAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-721-7844
Mailing Address - Street 1:1922 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8933
Mailing Address - Country:US
Mailing Address - Phone:904-721-7844
Mailing Address - Fax:904-727-3597
Practice Address - Street 1:1922 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8933
Practice Address - Country:US
Practice Address - Phone:904-721-7844
Practice Address - Fax:904-727-3597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA080025632OtherPALMETTO GBA - RAILROAD
FL15776OtherBLUE CROSS BLUE SHIELD
FL15776ZMedicare PIN
GA080025632OtherPALMETTO GBA - RAILROAD
FLK0701Medicare ID - Type UnspecifiedMEDICARE PRACTICE ID#
GA080025632Medicare PIN
FL15776OtherBLUE CROSS BLUE SHIELD