Basic Information
Provider Information | |||||||||
NPI: | 1336111392 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOULWARE | ||||||||
FirstName: | WENDELL | ||||||||
MiddleName: | G. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1150 VARNUM ST NE | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200172104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028544812 | ||||||||
FaxNumber: | 2028547825 | ||||||||
Practice Location | |||||||||
Address1: | 1150 VARNUM ST NE | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200172104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028544041 | ||||||||
FaxNumber: | 2028544034 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2006 | ||||||||
LastUpdateDate: | 11/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D60523 | MD | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | MD33486 | DC | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.