Provider Demographics
NPI:1962660589
Name:BOGHARA, HARESHKUMAR D (MD)
Entity type:Individual
Prefix:
First Name:HARESHKUMAR
Middle Name:D
Last Name:BOGHARA
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 1:951 YORK DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2052
Mailing Address - Country:US
Mailing Address - Phone:972-777-6956
Mailing Address - Fax:972-777-6922
Practice Address - Street 1:935 YORK DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2043
Practice Address - Country:US
Practice Address - Phone:972-777-6956
Practice Address - Fax:972-777-6922
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX277636YLPSOtherWELLMED MEDICAL GROUP
NCNC2199AMedicare PIN
KY00280116Medicare PIN
KY00503037Medicare PIN