Provider Demographics
NPI:1679597561
Name:BOE, JOHN MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:BOE
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5166
Practice Address - Country:US
Practice Address - Phone:317-880-3900
Practice Address - Fax:317-880-0545
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058907A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200234760Medicaid
IN000000668552OtherANTHEM PIN
INM400020128Medicare PIN
INP01030846Medicare PIN