1619960119 NPI number — DR. JOSEPH HOUSTON BOSLEY MD

Table of content: DR. JOSEPH HOUSTON BOSLEY MD (NPI 1619960119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619960119 NPI number — DR. JOSEPH HOUSTON BOSLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSLEY
Provider First Name:
JOSEPH
Provider Middle Name:
HOUSTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOSLEY
Provider Other First Name:
J
Provider Other Middle Name:
HOUSTON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1619960119
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2533 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Mailing Address:
#104
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71118-3158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-688-8801
Provider Business Mailing Address Fax Number:
318-688-8861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2533 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
#104
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-688-8801
Provider Business Practice Location Address Fax Number:
318-688-8861
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  06657R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1353523 . This is a "LSU MEDICAID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1799611 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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