Provider Demographics
NPI:1043275563
Name:BOSWORTH, MICHELE C (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:C
Last Name:BOSWORTH
Suffix:
Gender:F
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:PO BOX 731912
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1912
Mailing Address - Country:US
Mailing Address - Phone:903-877-7777
Mailing Address - Fax:903-877-5080
Practice Address - Street 1:11937 US HIGHWAY 271
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-3154
Practice Address - Country:US
Practice Address - Phone:903-877-7777
Practice Address - Fax:903-877-5080
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC160378Medicare UPIN
NC2053462OtherMEDICARE PROVIDER#