Provider Demographics
NPI:1962414839
Name:BOSE, SUDESHNA C (MD)
Entity type:Individual
Prefix:
First Name:SUDESHNA
Middle Name:C
Last Name:BOSE
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 1:3838 N CAMPBELL AVE, BLDG 2
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719
Mailing Address - Country:US
Mailing Address - Phone:520-694-8888
Mailing Address - Fax:520-694-0235
Practice Address - Street 1:3838 N CAMPBELL AVE, BLDG 2
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719
Practice Address - Country:US
Practice Address - Phone:520-694-8888
Practice Address - Fax:520-694-0235
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ304332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ704587Medicaid
AZZWCGCROtherGROUP MEDICARE NUMBER
AZZ70777Medicare PIN
AZ704587Medicaid