Provider Demographics
NPI:1902125503
Name:BOCANEGRA, INGRID
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:BOCANEGRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 270714
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77277-0714
Mailing Address - Country:US
Mailing Address - Phone:305-915-3064
Mailing Address - Fax:
Practice Address - Street 1:4800 FOURNACE PL
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2324
Practice Address - Country:US
Practice Address - Phone:346-426-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
IN01073251A207Q00000X
TXR0362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000851833OtherANTHEM PIN FOR FAMILY MEDICINE TIN 35-2030653
IN000000865042OtherANTHEM URGENT CARE PIN FOR TIN 35-2030653
IN201093580Medicaid
IN000000865042OtherANTHEM URGENT CARE PIN FOR TIN 35-2030653
IN000000851833OtherANTHEM PIN FOR FAMILY MEDICINE TIN 35-2030653