Provider Demographics
NPI:1194988790
Name:BOSAK, DAVID MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:BOSAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 S PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-5975
Mailing Address - Country:US
Mailing Address - Phone:517-393-2660
Mailing Address - Fax:517-393-1313
Practice Address - Street 1:6425 S PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-5975
Practice Address - Country:US
Practice Address - Phone:517-393-2660
Practice Address - Fax:517-393-1313
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist