Provider Demographics
NPI:1659478618
Name:BOECKMANN, RICHARD RONALD (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:RONALD
Last Name:BOECKMANN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 E UTOPIA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-3966
Mailing Address - Country:US
Mailing Address - Phone:602-867-8335
Mailing Address - Fax:
Practice Address - Street 1:16421 N TATUM BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3454
Practice Address - Country:US
Practice Address - Phone:602-923-6600
Practice Address - Fax:602-923-6611
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ71678Medicare ID - Type Unspecified