Provider Demographics
NPI:1467520163
Name:BOSSENBERGER, JEFFERY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:
Last Name:BOSSENBERGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 SILVER PKWY
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3423
Mailing Address - Country:US
Mailing Address - Phone:810-714-9660
Mailing Address - Fax:810-714-9661
Practice Address - Street 1:17200 SILVER PKWY
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-4437
Practice Address - Country:US
Practice Address - Phone:810-714-9660
Practice Address - Fax:810-714-9661
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3278563Medicaid
MI3278563Medicaid
MIP20150003Medicare PIN