Provider Demographics
NPI:1841362332
Name:BOEZI, MONIQUE A (DO)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:A
Last Name:BOEZI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 KNIGHTSBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-2352
Mailing Address - Country:US
Mailing Address - Phone:614-451-9612
Mailing Address - Fax:614-451-2009
Practice Address - Street 1:4825 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2352
Practice Address - Country:US
Practice Address - Phone:614-451-9612
Practice Address - Fax:614-451-2009
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0150698Medicaid
OH0150698Medicaid
OH0784226Medicare PIN