Provider Demographics
NPI:1093776817
Name:BOSTON, JOSE S (MD,CMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:S
Last Name:BOSTON
Suffix:
Gender:M
Credentials:MD,CMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 OLD COURT RD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5103
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:3704 EGERTON RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-7115
Practice Address - Country:US
Practice Address - Phone:410-367-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD28462207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCN6601OtherR/R MEDICARE GROUP #
MD110168890OtherR/R MEDICARE PROVIDER #
MDCN6601OtherR/R MEDICARE GROUP #
MDH330Medicare PIN
MDKL09HP36Medicare PIN
MDKL19065YMedicare PIN
MD171786ZCKJMedicare PIN