Provider Demographics
NPI:1558344937
Name:BOSCHERT, GREGORY RANDOLPH (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RANDOLPH
Last Name:BOSCHERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S CENTRAL AVE BOX 537
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-2002
Mailing Address - Country:US
Mailing Address - Phone:636-938-9092
Mailing Address - Fax:636-938-3105
Practice Address - Street 1:101 S. CENTRAL AVE. POBOX 537
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-2002
Practice Address - Country:US
Practice Address - Phone:636-938-9092
Practice Address - Fax:636-938-3105
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T42634Medicare UPIN
MO0156580001Medicare ID - Type Unspecified