Provider Demographics
NPI:1912059445
Name:BOSCHULTE, JUALENDA (MD)
Entity type:Individual
Prefix:
First Name:JUALENDA
Middle Name:
Last Name:BOSCHULTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 BENNING RD NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4569
Mailing Address - Country:US
Mailing Address - Phone:301-602-6661
Mailing Address - Fax:
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:SUITE 307
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017
Practice Address - Country:US
Practice Address - Phone:301-602-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD20905207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC011584900Medicaid
DCBB553521Medicare ID - Type Unspecified
DC011584900Medicaid