Provider Demographics
NPI:1548209612
Name:BOSWELL, WILLIAM DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:BOSWELL
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 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:626-775-3514
Mailing Address - Fax:626-218-5310
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-359-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG266732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G266730Medicaid
CA00G266730G56OtherCAL OPTIMA
CA300031894OtherRAIL ROAD MEDICARE
CA00G266730OtherBLUE SHIELD
CAA43063Medicare UPIN
CAWG26673JMedicare PIN
CA00G266730G56OtherCAL OPTIMA
CAWG26673LMedicare PIN
CAWG26673MMedicare PIN