Basic Information
| Provider Information | |||||||||
| NPI: | 1477087021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSTROM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BOSTROM | ||||||||
| OtherFirstName: | JACK | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 550 FIRST AVENUE | ||||||||
| Address2: | NYU LANGONE MEDICAL CENTER | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122635506 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 FIRST AVENUE | ||||||||
| Address2: | NYU LANGONE MEDICAL CENTER | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122635506 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2017 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.