Provider Demographics
NPI:1750459301
Name:BOSSON, MICHAEL A (LO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:BOSSON
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 VILLAGE GREEN DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3419
Mailing Address - Country:US
Mailing Address - Phone:860-567-4565
Mailing Address - Fax:
Practice Address - Street 1:33 VILLAGE GREEN DR
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759
Practice Address - Country:US
Practice Address - Phone:860-567-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT737156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT100000737CT01OtherANTHEM BLUE CROSS BLUE SH