Provider Demographics
NPI:1700299773
Name:BOEHM, BROCK EUGENE (DO)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:EUGENE
Last Name:BOEHM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1942
Mailing Address - Country:US
Mailing Address - Phone:515-505-0893
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST # MC3240
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4597
Practice Address - Country:US
Practice Address - Phone:303-436-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-08
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204301208800000X, 208D00000X
CODR.0071211208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice