Provider Demographics
NPI:1528147410
Name:BOSCHETTI, JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BOSCHETTI
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 1:580 REED ROAD
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008
Mailing Address - Country:US
Mailing Address - Phone:610-353-6767
Mailing Address - Fax:610-325-0888
Practice Address - Street 1:580 REED ROAD
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008
Practice Address - Country:US
Practice Address - Phone:610-353-6767
Practice Address - Fax:610-325-0888
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05004442L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1071929Medicaid
PA477697OtherHIGHMARK BLUE SHIELD
PA0032117001OtherKEYSTONE
PA5795035OtherAETNA
B42185Medicare UPIN
PA477697OtherHIGHMARK BLUE SHIELD