Provider Demographics
NPI:1750464178
Name:BOSCH, MIGUEL ANGEL (OD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:BOSCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 WRIGHTSBORO RD
Mailing Address - Street 2:SUITE 1325
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0566
Mailing Address - Country:US
Mailing Address - Phone:706-736-9929
Mailing Address - Fax:706-736-9967
Practice Address - Street 1:3450 WRIGHTSBORO RD
Practice Address - Street 2:SUITE 1325
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-0566
Practice Address - Country:US
Practice Address - Phone:706-736-9929
Practice Address - Fax:706-736-9967
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
41ZCBVKMedicare ID - Type Unspecified
U25280Medicare UPIN