Provider Demographics
NPI:1356434104
Name:CHEN, BO (MD)
Entity type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:CHEN
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 1:98 E BROADWAY
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7181
Mailing Address - Country:US
Mailing Address - Phone:212-343-9261
Mailing Address - Fax:212-343-9718
Practice Address - Street 1:98 E BROADWAY
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7181
Practice Address - Country:US
Practice Address - Phone:212-343-9261
Practice Address - Fax:212-343-9718
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01957900Medicaid
NY56N951Medicare PIN
NY01957900Medicaid