Provider Demographics
NPI:1821092420
Name:BOSTANCHE, JOHN L (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:BOSTANCHE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6123 GREEN BAY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2939
Mailing Address - Country:US
Mailing Address - Phone:262-657-3668
Mailing Address - Fax:262-652-0564
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:STE 100
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2939
Practice Address - Country:US
Practice Address - Phone:262-657-3668
Practice Address - Fax:262-652-0564
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI654025213ES0103X
IL016004510213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43215000Medicaid
WI43215000Medicaid
WI1821092420Medicare NSC
U18653Medicare UPIN