Provider Demographics
NPI:1871591966
Name:BOESEN, PETER VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:VINCENT
Last Name:BOESEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1000 73RD ST
Mailing Address - Street 2:SUITE 18
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50311-1321
Mailing Address - Country:US
Mailing Address - Phone:515-267-0691
Mailing Address - Fax:515-267-0790
Practice Address - Street 1:1000 73RD ST
Practice Address - Street 2:SUITE 18
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50311-1321
Practice Address - Country:US
Practice Address - Phone:515-267-0691
Practice Address - Fax:515-267-0790
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA26113207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3058156Medicaid
IA3058156Medicaid
D89646Medicare UPIN