Provider Demographics
NPI:1568405785
Name:BOSE, SHISHIR K (MD)
Entity Type:Individual
Prefix:DR
First Name:SHISHIR
Middle Name:K
Last Name:BOSE
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 1:1000 ZECKENDORF BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2133
Mailing Address - Country:US
Mailing Address - Phone:516-542-6880
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:31-75 23RD ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106
Practice Address - Country:US
Practice Address - Phone:718-956-2200
Practice Address - Fax:718-956-2316
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01722834Medicaid
NY25810Medicare ID - Type Unspecified
NY01722834Medicaid
NYF04196Medicare UPIN