Provider Demographics
NPI:1649274101
Name:BOSCO, JAY W (OD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:W
Last Name:BOSCO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 W CENTER RD
Mailing Address - Street 2:STE 14
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-2143
Mailing Address - Country:US
Mailing Address - Phone:989-892-5555
Mailing Address - Fax:989-892-9525
Practice Address - Street 1:1480 W CENTER RD
Practice Address - Street 2:STE 14
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-2143
Practice Address - Country:US
Practice Address - Phone:989-892-5555
Practice Address - Fax:989-892-9525
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002847152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI94-4445853Medicaid
MI944445853Medicaid
5383560001Medicare NSC
MI0N59010Medicare PIN
MI944445853Medicaid