Provider Demographics
NPI:1982823100
Name:BOSE, DEBARATI BANERJI (MD)
Entity Type:Individual
Prefix:
First Name:DEBARATI
Middle Name:BANERJI
Last Name:BOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 US HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9129
Mailing Address - Country:US
Mailing Address - Phone:630-646-4255
Mailing Address - Fax:630-646-4256
Practice Address - Street 1:6701 US HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9129
Practice Address - Country:US
Practice Address - Phone:630-646-4255
Practice Address - Fax:630-646-4256
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19828231001Medicaid