Provider Demographics
NPI:1942312921
Name:BOSLEY, CARL EUGENE (DO)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:EUGENE
Last Name:BOSLEY
Suffix:
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 1:2503 LUCY LEE PKWY
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2444
Mailing Address - Country:US
Mailing Address - Phone:573-785-5544
Mailing Address - Fax:573-785-4672
Practice Address - Street 1:2503 LUCY LEE PKWY
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2444
Practice Address - Country:US
Practice Address - Phone:573-785-5544
Practice Address - Fax:573-785-4672
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8584207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO246988901Medicaid
MO246988901Medicaid
MO000003202Medicare PIN