Provider Demographics
NPI:1750365813
Name:BOSHRA, SOHEIR (MD)
Entity type:Individual
Prefix:
First Name:SOHEIR
Middle Name:
Last Name:BOSHRA
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 1:5325 FOX RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-4955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW
Practice Address - Street 2:SUITE 302
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2462
Practice Address - Country:US
Practice Address - Phone:540-981-7653
Practice Address - Fax:540-981-7469
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-235582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010092892Medicaid
VA010092906Medicaid
VA010117224Medicaid
VAI16524Medicare UPIN
005422C19Medicare PIN
VA010117224Medicaid