Provider Demographics
NPI:1942235783
Name:BOSSHARDT, RICHARD T (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:BOSSHARDT
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 1:1879 NIGHTINGALE LN
Mailing Address - Street 2:A-2
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4363
Mailing Address - Country:US
Mailing Address - Phone:352-742-0079
Mailing Address - Fax:352-742-0059
Practice Address - Street 1:1879 NIGHTINGALE LN
Practice Address - Street 2:A-2
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4363
Practice Address - Country:US
Practice Address - Phone:352-742-0079
Practice Address - Fax:352-742-0059
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49691208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08371OtherBLUE SHIELD
FL035625500Medicaid
FL035625500Medicaid
FLE21817Medicare UPIN