Provider Demographics
NPI:1023095379
Name:BOSCALJON, REBECCA J (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:BOSCALJON
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2593 HOLIDAY RD
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2781
Practice Address - Country:US
Practice Address - Phone:319-339-1231
Practice Address - Fax:319-688-2930
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36060208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0464974Medicaid
IAI16620Medicare PIN
IA0464974Medicaid