Provider Demographics
NPI:1477182111
Name:BOSE, SANUJA (MD)
Entity type:Individual
Prefix:DR
First Name:SANUJA
Middle Name:
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 1:1205 W 65TH ST UNIT 7701
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:585-474-8243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMT221503390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program