Basic Information
| Provider Information | |||||||||
| NPI: | 1679791875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSAK | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1613 N. HARRISON PARKWAY | ||||||||
| Address2: | SUITE 200, MAILSTOP SH-9A | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548382371 | ||||||||
| FaxNumber: | 9548511746 | ||||||||
| Practice Location | |||||||||
| Address1: | 83 W MILLER ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218432584 | ||||||||
| FaxNumber: | 3522656922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 08/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME110241 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MT188050 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 003763000 | 05 | FL | MEDICAID |