Provider Demographics
NPI:1790719888
Name:BOEHM, HENRY JULIUS (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:JULIUS
Last Name:BOEHM
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:PO BOX 1888
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:903-453-2541
Practice Address - Street 1:3000 HERRING AVENUE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708
Practice Address - Country:US
Practice Address - Phone:254-202-2000
Practice Address - Fax:254-753-6229
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ51432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102082803Medicaid
TX102082801Medicaid
TX84R124Medicare PIN
TX102082803Medicaid
TX8555M9Medicare PIN
TX300122017Medicare PIN
F72521Medicare UPIN