Provider Demographics
NPI:1689671976
Name:BOEHM, KARIN N (OD)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:N
Last Name:BOEHM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KARIN
Other - Middle Name:N
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:6880 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4270
Mailing Address - Country:US
Mailing Address - Phone:707-823-7628
Mailing Address - Fax:707-823-1581
Practice Address - Street 1:6880 PALM AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4270
Practice Address - Country:US
Practice Address - Phone:707-823-7628
Practice Address - Fax:707-823-1581
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12314T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0123140Medicaid
U97059Medicare UPIN
CASD0123140Medicare ID - Type Unspecified