Provider Demographics
NPI:1508824772
Name:BOORAS, CHARLES H (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:BOORAS
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1922 UNIVERSITY BLVD S
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8933
Practice Address - Country:US
Practice Address - Phone:904-721-7844
Practice Address - Fax:904-727-3597
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 40719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA080025632OtherPALMETTO GBA - RAILROAD
FLP00640149OtherRR MEDICARE
FL15576YMedicare PIN
FLK0701Medicare PIN
FLD52732Medicare UPIN
GA080025632Medicare PIN
FL15776ZMedicare ID - Type Unspecified