Provider Demographics
NPI:1831539105
Name:BOESKOOL, ZACHARY (OD)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:BOESKOOL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 WILSON AVE NW
Mailing Address - Street 2:STE E
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-7986
Mailing Address - Country:US
Mailing Address - Phone:616-261-3939
Mailing Address - Fax:616-261-3940
Practice Address - Street 1:2209 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-0902
Practice Address - Country:US
Practice Address - Phone:912-285-2021
Practice Address - Fax:912-285-2558
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004774152W00000X
GAOPT003146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist