Provider Demographics
NPI:1740295302
Name:BOSSOLO, JOSE ANTONIO JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ANTONIO
Last Name:BOSSOLO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1203 E ALTON GLOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-0004
Mailing Address - Country:US
Mailing Address - Phone:956-504-6996
Mailing Address - Fax:956-544-6545
Practice Address - Street 1:1203 E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-0004
Practice Address - Country:US
Practice Address - Phone:956-504-6996
Practice Address - Fax:956-544-6545
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8020207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145509901Medicaid
TXH11696Medicare UPIN
TX145509901Medicaid