Provider Demographics
NPI:1912032962
Name:BOSCH, THEODORE R (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:R
Last Name:BOSCH
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 1:1064 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-2251
Mailing Address - Country:US
Mailing Address - Phone:559-687-2344
Mailing Address - Fax:559-687-2013
Practice Address - Street 1:1064 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-2251
Practice Address - Country:US
Practice Address - Phone:559-687-2344
Practice Address - Fax:559-687-2013
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75333208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A753330OtherBLUE SHIELD
CA00A753330OtherBLUE CROSS
CA00A753330Medicaid
CA00A753330Medicare ID - Type Unspecified
CA00A753330OtherBLUE SHIELD