Provider Demographics
NPI:1629162615
Name:KAWLICHE, BORIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:KAWLICHE
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 1:407 N PARSONS AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4537
Mailing Address - Country:US
Mailing Address - Phone:813-681-5880
Mailing Address - Fax:813-681-5958
Practice Address - Street 1:407 N PARSONS AVE STE 104
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4537
Practice Address - Country:US
Practice Address - Phone:813-681-5880
Practice Address - Fax:813-681-5958
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME665002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378031700Medicaid
FLHO331AMedicare PIN