Provider Demographics
NPI:1700869252
Name:BOSWELL, ROBERT JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:BOSWELL
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 1:2233 NESCONSET HWY
Mailing Address - Street 2:STE 202
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1000
Mailing Address - Country:US
Mailing Address - Phone:631-585-5055
Mailing Address - Fax:631-585-4967
Practice Address - Street 1:2233 NESCONSET HWY
Practice Address - Street 2:STE 202
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1000
Practice Address - Country:US
Practice Address - Phone:631-585-5055
Practice Address - Fax:631-585-4967
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00669172Medicaid
C07467Medicare UPIN
NY00669172Medicaid