Provider Demographics
NPI:1679791875
Name:BOSAK, JODI L (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:BOSAK
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 1:1613 N. HARRISON PARKWAY
Mailing Address - Street 2:SUITE 200, MAILSTOP SH-9A
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2896
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:954-851-1746
Practice Address - Street 1:83 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2031
Practice Address - Country:US
Practice Address - Phone:321-843-2584
Practice Address - Fax:352-265-6922
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110241207L00000X
PAMT188050207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003763000Medicaid
FL003763000Medicaid