Provider Demographics
NPI:1609161165
Name:BOEHM, JULIE MIYO KUMATA (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:MIYO KUMATA
Last Name:BOEHM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:434-972-4266
Practice Address - Street 1:1300 JEFFERSON PARK AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3363
Practice Address - Country:US
Practice Address - Phone:434-924-5485
Practice Address - Fax:434-924-5180
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136111207W00000X
VA0101264155207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAINTERNMedicaid