Basic Information
| Provider Information | |||||||||
| NPI: | 1205849809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOEKE | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656133011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173286501 | ||||||||
| FaxNumber: | 4173286338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 S 3RD | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657859608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172765131 | ||||||||
| FaxNumber: | 4172766498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 12/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO107694 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 107694 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00062527 | 01 | MO | PALMETTO GBA RAILRAOD | OTHER |