Provider Demographics
NPI:1659458313
Name:BOEHLE, KEVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:BOEHLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 SHADY MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15800 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4259
Practice Address - Country:US
Practice Address - Phone:972-720-7909
Practice Address - Fax:972-720-7778
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ99782083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z957Medicare PIN
G20838Medicare UPIN
TX8L22785Medicare UPIN