Provider Demographics
NPI:1770674715
Name:BOEHM, MARY ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ROSE
Last Name:BOEHM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E HIGHWAY 50
Mailing Address - Street 2:BOX 304
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3164
Mailing Address - Country:US
Mailing Address - Phone:352-242-1430
Mailing Address - Fax:352-242-1452
Practice Address - Street 1:200 E. HIGHLAND AVE.
Practice Address - Street 2:SUITE 2
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2712
Practice Address - Country:US
Practice Address - Phone:352-242-1430
Practice Address - Fax:352-242-1452
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7042549OtherAETNA
FL161683483OtherHUMANA
FL81213OtherBC/BS
FL268746100Medicaid
FL81213ZMedicare ID - Type Unspecified
FL81213OtherBC/BS