Provider Demographics
NPI:1952418659
Name:BOSTROM, MATHIAS PG (MD)
Entity Type:Individual
Prefix:DR
First Name:MATHIAS
Middle Name:PG
Last Name:BOSTROM
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 29234
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4872
Mailing Address - Country:US
Mailing Address - Phone:212-606-1674
Mailing Address - Fax:212-472-3713
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:212-606-1674
Practice Address - Fax:212-472-3713
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2024-01-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY183199207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01706812Medicaid
NYG22045Medicare UPIN
NY01706812Medicaid