Provider Demographics
NPI:1487658894
Name:BOSACK, DOUGLAS P (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
Last Name:BOSACK
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 790
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-0790
Mailing Address - Country:US
Mailing Address - Phone:304-536-5030
Mailing Address - Fax:304-536-5031
Practice Address - Street 1:RR 2 BOX 171
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9318
Practice Address - Country:US
Practice Address - Phone:304-345-9023
Practice Address - Fax:304-645-9025
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21789207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001625Medicaid
WV3810001625Medicaid
A15403Medicare UPIN