Provider Demographics
NPI:1306422811
Name:THEODORE, BOSCO CODY (DO)
Entity type:Individual
Prefix:
First Name:BOSCO
Middle Name:CODY
Last Name:THEODORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7494
Mailing Address - Country:US
Mailing Address - Phone:540-776-4000
Mailing Address - Fax:
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7494
Practice Address - Country:US
Practice Address - Phone:540-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022079762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry