Provider Demographics
NPI:1821165853
Name:BOETCHER, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:BOETCHER
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 1:14300 GALLANT FOX LN
Mailing Address - Street 2:STE 118
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4003
Mailing Address - Country:US
Mailing Address - Phone:301-464-3020
Mailing Address - Fax:301-262-8703
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:STE 118
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-464-3020
Practice Address - Fax:301-262-8703
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0016063207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCB94188Medicare UPIN
DC175933D14Medicare PIN