Provider Demographics
NPI:1285797241
Name:BOE, ROGER W (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:BOE
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 1:226 S 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4003
Mailing Address - Country:US
Mailing Address - Phone:208-233-5651
Mailing Address - Fax:
Practice Address - Street 1:405 W WHITMAN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3317
Practice Address - Country:US
Practice Address - Phone:208-233-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM26912080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1111341Medicare ID - Type Unspecified
E04193Medicare UPIN