Provider Demographics
NPI:1760517759
Name:BOEHM, MARY (OD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:BOEHM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 GLENVIEW DR APT 209
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3708
Mailing Address - Country:US
Mailing Address - Phone:650-871-6206
Mailing Address - Fax:
Practice Address - Street 1:300 W PORTAL AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1412
Practice Address - Country:US
Practice Address - Phone:415-753-8511
Practice Address - Fax:415-753-5517
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12085T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist