Provider Demographics
NPI:1083666010
Name:BOGHOSSIAN, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BOGHOSSIAN
Suffix:
Gender:M
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 93
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-0093
Mailing Address - Country:US
Mailing Address - Phone:239-597-0704
Mailing Address - Fax:239-597-0709
Practice Address - Street 1:631 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3846
Practice Address - Country:US
Practice Address - Phone:973-364-2682
Practice Address - Fax:973-364-1430
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA81581207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4555104Medicaid
NJE97537Medicare UPIN
NJ4555104Medicaid