Provider Demographics
NPI:1174544530
Name:BOERSMA, DOROTHY C (MD, MPH)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:C
Last Name:BOERSMA
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-3754
Mailing Address - Country:US
Mailing Address - Phone:317-926-1507
Mailing Address - Fax:317-926-1508
Practice Address - Street 1:401 E 34TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3754
Practice Address - Country:US
Practice Address - Phone:317-926-1507
Practice Address - Fax:317-926-1508
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
46698002OtherMEDICARE
IN100216190Medicaid
IN100216190Medicaid
IND89959Medicare UPIN