Provider Demographics
NPI:1609211390
Name:TEN BOSCH, JOHN RODERICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RODERICK
Last Name:TEN BOSCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 COTTLE RD BLDG 6
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5755 COTTLE RD BLDG 6
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3640
Practice Address - Country:US
Practice Address - Phone:408-972-6752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTO653207SC0300X
CADRN64207SG0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics
No207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Cytogenetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADRN64OtherCALIFORNIA DEPARTMENT OF PUBLIC HEALTH - LAB FIELD SERVICES
CA2009152OtherAMERICAN BOARD OF MEDICAL GENETICS
CAMTO653OtherCALIFORNIA DEPARTMENT OF PUBLIC HEALTH - LAB FIELD SERVICES