Provider Demographics
NPI:1588656151
Name:BOECK, CARL ALLEN (OD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:ALLEN
Last Name:BOECK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9444 DOHENY RD
Mailing Address - Street 2:#50
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-2507
Mailing Address - Country:US
Mailing Address - Phone:619-449-2000
Mailing Address - Fax:
Practice Address - Street 1:9621 MISSION GORGE RD
Practice Address - Street 2:106
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3802
Practice Address - Country:US
Practice Address - Phone:619-449-2000
Practice Address - Fax:619-449-8303
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6620T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066200Medicaid
CAT10373Medicare UPIN
CAWOP6620AMedicare PIN