Provider Demographics
NPI:1962660589
Name:BOGHARA, HARESHKUMAR D (MD)
Entity Type:Individual
Prefix:
First Name:HARESHKUMAR
Middle Name:D
Last Name:BOGHARA
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 1:9353 ELAM RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-4181
Mailing Address - Country:US
Mailing Address - Phone:214-391-1158
Mailing Address - Fax:214-398-0212
Practice Address - Street 1:9353 ELAM RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4181
Practice Address - Country:US
Practice Address - Phone:214-391-1158
Practice Address - Fax:214-398-0212
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX277636YLPSOtherWELLMED MEDICAL GROUP
NCNC2199AMedicare PIN
KY00280116Medicare PIN
KY00503037Medicare PIN