Provider Demographics
NPI:1831195767
Name:BOSSLET, KENNETH (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BOSSLET
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 FAIRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-8144
Mailing Address - Country:US
Mailing Address - Phone:937-492-8431
Mailing Address - Fax:937-498-5126
Practice Address - Street 1:1205 FAIRINGTON DR
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-8144
Practice Address - Country:US
Practice Address - Phone:937-492-8431
Practice Address - Fax:937-498-5126
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0740578Medicaid
OH0740578Medicaid
OHE21513Medicare UPIN