Provider Demographics
NPI:1831120146
Name:BOAZ, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BOAZ
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 1:3053 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1720
Mailing Address - Country:US
Mailing Address - Phone:423-301-6567
Mailing Address - Fax:423-573-9672
Practice Address - Street 1:3053 W STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1720
Practice Address - Country:US
Practice Address - Phone:423-301-6567
Practice Address - Fax:423-573-9672
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC284332085R0202X
TN367502085R0202X
NC2002010502085R0202X
NVSP0152085R0202X
OH35-06-5316-B2085R0202X
WA417342085R0202X
MA2156412085R0202X
GA517812085R0202X
CAG844102085R0202X
IN01056485A2085R0202X
WI45134-202085R0202X
UT5222812-12052085R0202X
MI43010805882085R0202X
TXL79832085R0202X
NJ25MA074844002085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC6209AMedicare PIN
SCSC50346685Medicare PIN