Provider Demographics
NPI:1487682696
Name:BOARDMAN, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BOARDMAN
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 1:2629 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-4932
Mailing Address - Country:US
Mailing Address - Phone:920-451-5553
Mailing Address - Fax:920-451-5113
Practice Address - Street 1:2629 N 7TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-4932
Practice Address - Country:US
Practice Address - Phone:920-451-5553
Practice Address - Fax:920-451-5113
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27561207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30735200Medicaid
MI104363050Medicaid
WI930111410OtherRAILROAD
MI104363050Medicaid
WI015107650Medicare ID - Type Unspecified