Provider Demographics
NPI:1376599977
Name:BOSE, PRATIMA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRATIMA
Middle Name:
Last Name:BOSE
Suffix:
Gender:F
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 62026
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL PL
Practice Address - Street 2:BURK BLDG, SUITE 312
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9359
Practice Address - Fax:410-962-8393
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014826207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MHS190 / 0056OtherBLUE CHOICE
MDKF68 / 304350-01OtherBC/BS
MDKL28/96BBMedicare ID - Type Unspecified
MD052041100Medicare ID - Type Unspecified
MDKF68 / 304350-01OtherBC/BS