Provider Demographics
NPI:1497708242
Name:BOSTROM, JOHN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:BOSTROM
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 1:846 BERKLEY ST
Mailing Address - Street 2:APT. C
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-5405
Mailing Address - Country:US
Mailing Address - Phone:201-576-0999
Mailing Address - Fax:
Practice Address - Street 1:610 VALLEY HEALTH PLZ
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3607
Practice Address - Country:US
Practice Address - Phone:201-265-8200
Practice Address - Fax:201-265-0366
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02455300204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC58485Medicare UPIN
NJ560925Medicare ID - Type Unspecified