Provider Demographics
NPI:1912901760
Name:BOCCAROSSA, GERRY (DO)
Entity Type:Individual
Prefix:
First Name:GERRY
Middle Name:
Last Name:BOCCAROSSA
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 1:412 MOUNTAIN VIEW CT
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-6252
Mailing Address - Country:US
Mailing Address - Phone:423-220-0650
Mailing Address - Fax:
Practice Address - Street 1:412 MOUNTAIN VIEW CT
Practice Address - Street 2:
Practice Address - City:BLOUNTVILLE
Practice Address - State:TN
Practice Address - Zip Code:37617-6252
Practice Address - Country:US
Practice Address - Phone:423-220-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO 1162207R00000X
VA0102201244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3304613Medicaid
VA005830494Medicaid
TN3304613Medicare ID - Type Unspecified
TNCC0450Medicare PIN
E56418Medicare UPIN
TN3304613Medicaid
TN110190168Medicare PIN
VAC06181Medicare PIN
VAV V 2663AMedicare PIN
0281780001Medicare PIN
VA002975H81Medicare PIN
0281780003Medicare PIN