Provider Demographics
NPI:1689859068
Name:BOSSOLO, EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:BOSSOLO
Suffix:
Gender:M
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:#5101 PASEO EL VERDE
Mailing Address - Street 2:
Mailing Address - City:CAQUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:361-813-7798
Mailing Address - Fax:
Practice Address - Street 1:#5101 PASEO EL VERDE
Practice Address - Street 2:
Practice Address - City:CAQUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:361-813-7798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0087472083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C77396Medicare UPIN