Provider Demographics
NPI:1841225059
Name:BOEHM, OTTO ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:ROBERT
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 1:2630 E 7TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-4319
Mailing Address - Country:US
Mailing Address - Phone:704-372-7900
Mailing Address - Fax:704-376-2216
Practice Address - Street 1:2630 E 7TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4319
Practice Address - Country:US
Practice Address - Phone:704-372-7900
Practice Address - Fax:704-376-2216
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21627207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8916409Medicaid
NC01284OtherBCBS
C89315Medicare UPIN
NC2325437Medicare PIN