Provider Demographics
NPI:1407991912
Name:BOSSETTI, TIMOTHY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALAN
Last Name:BOSSETTI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10708 CHERT ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-1647
Mailing Address - Country:US
Mailing Address - Phone:915-821-6835
Mailing Address - Fax:
Practice Address - Street 1:8401 GATEWAY BLVD W
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-5657
Practice Address - Country:US
Practice Address - Phone:915-775-4916
Practice Address - Fax:915-833-6404
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3919OtherOPTOMETRY
TXT12291Medicare UPIN