Provider Demographics
NPI:1689639643
Name:BOEHMKE, FRED EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:EDWARD
Last Name:BOEHMKE
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 1:8201 MAIN ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6046
Mailing Address - Country:US
Mailing Address - Phone:716-626-6626
Mailing Address - Fax:716-626-6646
Practice Address - Street 1:8201 MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6046
Practice Address - Country:US
Practice Address - Phone:716-626-6626
Practice Address - Fax:716-626-6646
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130603208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00668933Medicaid
NYB71583Medicare UPIN
NY11995BMedicare ID - Type Unspecified