Provider Demographics
NPI:1043385875
Name:DR. GREGORY R. BOSCHERT, OPTOMETRIST
Entity Type:Organization
Organization Name:DR. GREGORY R. BOSCHERT, OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:BOSCHERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-352-7766
Mailing Address - Street 1:5223 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-1616
Mailing Address - Country:US
Mailing Address - Phone:314-352-7766
Mailing Address - Fax:
Practice Address - Street 1:5223 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-1616
Practice Address - Country:US
Practice Address - Phone:314-352-7766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T42634Medicare UPIN
MO0156580001Medicare ID - Type Unspecified