Provider Demographics
NPI:1952436289
Name:OVADIA, BOAZ (MD)
Entity type:Individual
Prefix:
First Name:BOAZ
Middle Name:
Last Name:OVADIA
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 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7060 N RECREATION AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8022
Practice Address - Country:US
Practice Address - Phone:559-325-5656
Practice Address - Fax:559-325-5568
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA924772080P0203X
FLME1046182080P0203X
MN105369- TEMP2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001125800Medicaid
FLBV993ZOtherMEDICARE PTAN