Basic Information
| Provider Information | |||||||||
| NPI: | 1437181989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOFFMAN | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | R | ||||||||
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| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 EUCLID AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919502957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192673020 | ||||||||
| FaxNumber: | 6192674042 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 EUCLID AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919502957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192673020 | ||||||||
| FaxNumber: | 6192674042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G258220 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G258220 | 05 | CA | MEDICAID |