Provider Demographics
NPI:1336269018
Name:BOOSTROM, SARAH YORK (MD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:YORK
Last Name:BOOSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 WORTH ST
Mailing Address - Street 2:SUITE 235
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2003
Mailing Address - Country:US
Mailing Address - Phone:214-820-8768
Mailing Address - Fax:214-820-8769
Practice Address - Street 1:3410 WORTH ST
Practice Address - Street 2:SUITE 235
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2003
Practice Address - Country:US
Practice Address - Phone:214-820-8768
Practice Address - Fax:214-820-8769
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN49678208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3293961-01Medicaid
MN450007000Medicaid
MN020002376Medicare PIN
MN020002863Medicare PIN
TX3293961-01Medicaid
MN450007000Medicaid