1659348514 NPI number — DR. GARY DOUGLAS BOZEMAN M.D.

Table of content: DR. GARY DOUGLAS BOZEMAN M.D. (NPI 1659348514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659348514 NPI number — DR. GARY DOUGLAS BOZEMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOZEMAN
Provider First Name:
GARY
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659348514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1226 E WATER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13210-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-478-4185
Provider Business Mailing Address Fax Number:
315-478-0840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 W BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13069-1533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-297-4700
Provider Business Practice Location Address Fax Number:
315-218-5898
Provider Enumeration Date:
02/28/2006

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: 208800000X , with the licence number:  272579 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 153372 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com