Provider Demographics
NPI:1568567741
Name:BOSLEY, GABRIELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:
Last Name:BOSLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:
Other - Last Name:BOSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6501 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-2101
Mailing Address - Country:US
Mailing Address - Phone:708-203-6659
Mailing Address - Fax:
Practice Address - Street 1:6501 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-2101
Practice Address - Country:US
Practice Address - Phone:708-203-6659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360973002085R0202X
CAG776392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1618334OtherBCBS ID
IL036097300Medicaid
H38514Medicare UPIN