Provider Demographics
NPI:1730112558
Name:BOULWARE, TERRY A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:A
Last Name:BOULWARE
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 1:2525 S TELSHOR BLVD
Mailing Address - Street 2:BLDG 14, STE 102
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5071
Mailing Address - Country:US
Mailing Address - Phone:505-522-7247
Mailing Address - Fax:505-522-2029
Practice Address - Street 1:2525 S TELSHOR BLVD
Practice Address - Street 2:BLDG 14, STE 102
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5071
Practice Address - Country:US
Practice Address - Phone:505-522-7247
Practice Address - Fax:505-522-2029
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0138207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33087512Medicaid
NMNM009V60OtherBCBS
NM33087512Medicaid
NMB21420Medicare UPIN