Provider Demographics
NPI:1871542001
Name:BOSTON, DAVID R (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:BOSTON
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 1:4530 SW FAIRHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2610
Mailing Address - Country:US
Mailing Address - Phone:503-224-0702
Mailing Address - Fax:
Practice Address - Street 1:400 NE MOTHER JOSEPH PL
Practice Address - Street 2:SW WASHINGTON MEDICAL CENTER
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-514-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA29739207UN0902X
WAMD00029739207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1075449Medicaid
WA1075449Medicaid
WAAB12915Medicare PIN