Healthcare Provider Details

I. General information

NPI: 1417910076
Provider Name (Legal Business Name): KANCHANA BOSEROY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 09/26/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 N BEVERLY AVE STE 101
TUCSON AZ
85712-2155
US

IV. Provider business mailing address

PO BOX 31235
TUCSON AZ
85751-1235
US

V. Phone/Fax

Practice location:
  • Phone: 520-324-6290
  • Fax: 520-324-6291
Mailing address:
  • Phone: 520-324-2308
  • Fax: 520-324-1406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200927
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number200927
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number56115
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: