Provider Demographics
NPI:1508894825
Name:BOEHM, THEODORE ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ALAN
Last Name:BOEHM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3400 W TECUMSEH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1810
Mailing Address - Country:US
Mailing Address - Phone:405-360-6764
Mailing Address - Fax:405-360-6769
Practice Address - Street 1:3400 W TECUMSEH RD STE 101
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1810
Practice Address - Country:US
Practice Address - Phone:405-360-6764
Practice Address - Fax:405-360-6769
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23491207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI27409Medicare UPIN