Provider Demographics
NPI:1558320051
Name:BOERSMA, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:BOERSMA
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 1:10330 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10801 N MICHIGAN RD STE 110
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-8171
Practice Address - Country:US
Practice Address - Phone:317-344-1269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ01028548OtherIN LIC #
IL000000355597OtherANTHEM
IN100216200Medicaid
INM400014753Medicare PIN
IN100216200Medicaid
IN100216200Medicaid