Provider Demographics
NPI:1477087021
Name:BOSTROM, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:BOSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:550 FIRST AVENUE
Mailing Address - Street 2:NYU LANGONE MEDICAL CENTER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-263-5506
Mailing Address - Fax:
Practice Address - Street 1:550 FIRST AVENUE
Practice Address - Street 2:NYU LANGONE MEDICAL CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-263-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program