Provider Demographics
NPI:1497733174
Name:BOULWARE, FREDERICK THORNTON (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:THORNTON
Last Name:BOULWARE
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 1:2423 W DUNLAP AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5818
Mailing Address - Country:US
Mailing Address - Phone:602-424-4450
Mailing Address - Fax:602-424-4451
Practice Address - Street 1:2423 W DUNLAP AVE
Practice Address - Street 2:STE 130
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5818
Practice Address - Country:US
Practice Address - Phone:602-424-4450
Practice Address - Fax:602-424-4451
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ377012084N0400X, 2084N0600X, 2084N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002038Medicaid
NV100500484Medicaid
NV002002038Medicaid
NV104810Medicare PIN