Provider Demographics
NPI:1679537260
Name:BOSE, SUDIP K
Entity Type:Individual
Prefix:DR
First Name:SUDIP
Middle Name:K
Last Name:BOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 LBJ FWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3405
Mailing Address - Country:US
Mailing Address - Phone:972-739-3710
Mailing Address - Fax:
Practice Address - Street 1:9229 LBJ FWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3405
Practice Address - Country:US
Practice Address - Phone:972-739-3710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5682207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH85285Medicare UPIN