Provider Demographics
NPI:1497723845
Name:BOOCKVAR, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BOOCKVAR
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:PO BOX 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:205-297-9411
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-6508
Practice Address - Country:US
Practice Address - Phone:205-731-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL45113207QG0300X, 207RG0300X
NY1967511207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01712138Medicaid
G38109Medicare UPIN
NY01712138Medicaid