Basic Information
| Provider Information | |||||||||
| NPI: | 1376834119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOHER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W HIBISCUS BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212654409 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 475 S JOHN RODES BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329041093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124111703 | ||||||||
| FaxNumber: | 3212411171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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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 | 106E00000X | FL | Y |
No ID Information.