Provider Demographics
NPI:1881651271
Name:BOSSIAN, JOHN LEON II (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEON
Last Name:BOSSIAN
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 ILIAINA ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1812
Mailing Address - Country:US
Mailing Address - Phone:808-448-6100
Mailing Address - Fax:
Practice Address - Street 1:15TH MDOS JBPH
Practice Address - Street 2:CIRCLE ROAD
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-448-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDO1419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI5820708Medicaid
RIJB35286Medicaid
RIMS46923OtherWELFARE
RI5820708Medicaid