Basic Information
| Provider Information | |||||||||
| NPI: | 1811998842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOHSALI | ||||||||
| FirstName: | KAMAL | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 117345 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463465 | ||||||||
| FaxNumber: | 9048586489 | ||||||||
| Practice Location | |||||||||
| Address1: | 1577 ROBERTS DR | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042411204 | ||||||||
| FaxNumber: | 9042417331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2005 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 050868 | GA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | ME95144 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | M1028 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016294500 | 05 | FL | MEDICAID |