Provider Demographics
NPI:1619116548
Name:BOSE, JOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOLLY
Middle Name:
Last Name:BOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N STATE ROAD 19
Mailing Address - Street 2:SUIT 48 NF/SG VAHS PALATKA CBOC
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-2482
Mailing Address - Country:US
Mailing Address - Phone:386-329-8800
Mailing Address - Fax:
Practice Address - Street 1:400 N STATE ROAD 19
Practice Address - Street 2:SUITE 48
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-2482
Practice Address - Country:US
Practice Address - Phone:386-329-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105828207QA0505X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine