# DR. JAKE P BOSTROM

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1295886125
- **Gender:** Man
- **Credential:** M.D.

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207W00000X | Ophthalmology Physician | 31615 | SC | Yes |

## Other

- **Enumeration date:** 01/16/2007
- **Last updated:** 07/09/2019

## 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 |