Provider Demographics
NPI:1609912146
Name:BOULWARE, PAUL CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:CHRISTOPHER
Last Name:BOULWARE
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 1:16620 N 40TH ST STE E1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3357
Mailing Address - Country:US
Mailing Address - Phone:602-464-9576
Mailing Address - Fax:480-428-0475
Practice Address - Street 1:16620 N 40TH ST STE E-1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3348
Practice Address - Country:US
Practice Address - Phone:602-464-9576
Practice Address - Fax:602-626-8901
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ417262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ435556Medicaid
AZZ130727Medicare PIN