Provider Demographics
NPI:1104958156
Name:BOSSHARDT, THOMAS LEE (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
Last Name:BOSSHARDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 E CHURCH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5915
Mailing Address - Country:US
Mailing Address - Phone:805-346-3456
Mailing Address - Fax:805-346-3454
Practice Address - Street 1:1325 E CHURCH ST STE 202
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5915
Practice Address - Country:US
Practice Address - Phone:805-346-3456
Practice Address - Fax:805-346-3454
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78405208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G784050Medicaid
CAF28537Medicare UPIN
CA00G784050Medicaid