Provider Demographics
NPI:1679552053
Name:BOHLE, DANIEL JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
Last Name:BOHLE
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 1:1311 N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2231
Mailing Address - Country:US
Mailing Address - Phone:970-564-2104
Mailing Address - Fax:970-564-2134
Practice Address - Street 1:20 S MARKET ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3502
Practice Address - Country:US
Practice Address - Phone:970-565-4291
Practice Address - Fax:970-565-4419
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18988207VG0400X
CO50974207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2206128Medicaid
CO40327558Medicaid
AZ698753Medicaid
COCOA107746Medicare PIN
IA2206128Medicaid
AZ698753Medicaid