Individual
DR. JAKE P BOSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1520 BOILING SPRINGS RD, BOILING SPRINGS, SC 29316
(864) 583-6381
(864) 583-6390
Mailing address
479 HEYWOOD AVE, SPARTANBURG, SC 29307-1726
(864) 583-6381
(864) 583-6390
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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