Provider Demographics
NPI:1851475750
Name:BOYSEN, THOMAS CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CHARLES
Last Name:BOYSEN
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 1:501 12TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1774
Mailing Address - Country:US
Mailing Address - Phone:319-337-3177
Mailing Address - Fax:319-341-0024
Practice Address - Street 1:501 12TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1774
Practice Address - Country:US
Practice Address - Phone:319-337-3177
Practice Address - Fax:319-341-0024
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24303207N00000X, 207ND0101X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA24829OtherWELLMARK BCBS
IA0000A30001OtherUHC OF RIVER VALLEY
IA0042135Medicaid
IA0042135Medicaid