Provider Demographics
NPI:1083678569
Name:VAN DEN BOSCH, JOHN T (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:VAN DEN BOSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3335
Mailing Address - Country:US
Mailing Address - Phone:610-372-8044
Mailing Address - Fax:484-334-7026
Practice Address - Street 1:950B N WYOMISSING BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1783
Practice Address - Country:US
Practice Address - Phone:610-898-1820
Practice Address - Fax:610-376-0164
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014906E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000645990Medicaid
PA000645990Medicaid
PA076513Medicare PIN