Provider Demographics
NPI:1427068436
Name:BOEHME, LARRY R (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:BOEHME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1899 N MARINE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6555
Mailing Address - Country:US
Mailing Address - Phone:910-347-1515
Mailing Address - Fax:910-347-7982
Practice Address - Street 1:1899 N MARINE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6555
Practice Address - Country:US
Practice Address - Phone:910-347-1515
Practice Address - Fax:910-347-7982
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B51622Medicare UPIN