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Individual
DR. JAKE P BOSTROM
Active
Individual
DR. JAKE P BOSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
31615
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1457384729
GROUP NPI
SC
01
—
31615
SC LICENSE
SC
05
—
316152
—
SC
01
—
AA3955-7292
MEDICARE PTAN
SC
01
—
P01501403
RR MEDICARE
SC
Enumeration date
01/16/2007
Last updated
07/09/2019
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