Provider Demographics
NPI:1457618662
Name:BOERCKER, GEOFFREY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:KEITH
Last Name:BOERCKER
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 1:925 BASS ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-8836
Mailing Address - Country:US
Mailing Address - Phone:360-220-1744
Mailing Address - Fax:
Practice Address - Street 1:1050 LARRABEE AVE
Practice Address - Street 2:#104-PMB 317
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7367
Practice Address - Country:US
Practice Address - Phone:360-220-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000267792084B0040X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1102243Medicaid
WA0116494OtherLABOR AND INDUSTRIES
WA1102243Medicaid