Provider Demographics
NPI:1245239714
Name:BOSSE, MATTHEW J (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:BOSSE
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 1168
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90078-1168
Mailing Address - Country:US
Mailing Address - Phone:323-993-7500
Mailing Address - Fax:323-308-4015
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-993-7500
Practice Address - Fax:323-308-4015
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75483174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA75483OtherSTATE LICENSE ID #
CA00A754830Medicaid
CABB7456759OtherDEA REGISTRATION #
CABB7456759OtherDEA REGISTRATION #
CAWA75483AMedicare ID - Type UnspecifiedMEDICARE ID #