Provider Demographics
NPI:1356411037
Name:BOMER, FAYE LOUIS (MD)
Entity type:Individual
Prefix:
First Name:FAYE
Middle Name:LOUIS
Last Name:BOMER
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 1:6838 N 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1056
Mailing Address - Country:US
Mailing Address - Phone:602-864-8800
Mailing Address - Fax:602-864-1448
Practice Address - Street 1:6838 N 23RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1056
Practice Address - Country:US
Practice Address - Phone:602-864-8800
Practice Address - Fax:602-864-1448
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:2006-08-15
Deactivation Code:
Reactivation Date:2006-11-07
Provider Licenses
StateLicense IDTaxonomies
AZ25031207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A50658Medicare UPIN