Provider Demographics
NPI:1982666137
Name:BOSTON, JOHN CECIL (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CECIL
Last Name:BOSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871830
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-1830
Mailing Address - Country:US
Mailing Address - Phone:907-376-2868
Mailing Address - Fax:907-376-2811
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:SUITE 228
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-376-2868
Practice Address - Fax:907-376-2811
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5285207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2914Medicaid
AK610518000OtherDEPARTMENT OF LABOR
AKDC8103OtherMEDICARE RAILROAD
AK201322021OtherTAX ID
AK610518000OtherDEPARTMENT OF LABOR
AK201322021OtherTAX ID