Provider Demographics
NPI:1932126901
Name:BOSE, SAJAL K (MD)
Entity Type:Individual
Prefix:
First Name:SAJAL
Middle Name:K
Last Name:BOSE
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 1:896 E MAIN ST
Mailing Address - Street 2:4
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1440
Mailing Address - Country:US
Mailing Address - Phone:317-887-2121
Mailing Address - Fax:317-887-5731
Practice Address - Street 1:896 E MAIN ST
Practice Address - Street 2:4
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1440
Practice Address - Country:US
Practice Address - Phone:317-887-2121
Practice Address - Fax:317-887-5731
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010310432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN595390AMedicare ID - Type UnspecifiedMEDICARE
INC24974Medicare UPIN