Provider Demographics
NPI:1659348514
Name:BOZEMAN, GARY DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DOUGLAS
Last Name:BOZEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1155
Mailing Address - Country:US
Mailing Address - Phone:315-478-4185
Mailing Address - Fax:315-478-0840
Practice Address - Street 1:806 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1533
Practice Address - Country:US
Practice Address - Phone:315-297-4700
Practice Address - Fax:315-218-5898
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272579208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC153372Medicaid
SCE895144300Medicare ID - Type Unspecified
SCE89514Medicare UPIN
SC7399Medicare PIN
SC153372Medicaid