Provider Demographics
NPI:1780834267
Name:BOEHLKE, SCOTT ALAN (LO)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALAN
Last Name:BOEHLKE
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 E CALIFORNIA AVE
Mailing Address - Street 2:100
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4224
Mailing Address - Country:US
Mailing Address - Phone:405-858-5200
Mailing Address - Fax:
Practice Address - Street 1:409 E CALIFORNIA AVE
Practice Address - Street 2:100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4224
Practice Address - Country:US
Practice Address - Phone:405-858-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist