Healthcare Provider Details

I. General information

NPI: 1104032630
Provider Name (Legal Business Name): ADRIAN A. BOSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 N. BREA BLVD.
BREA CA
92821-2606
US

IV. Provider business mailing address

1497 CASA GRANDE ST.
PASADENA CA
91104-3921
US

V. Phone/Fax

Practice location:
  • Phone: 714-529-6842
  • Fax: 714-256-1041
Mailing address:
  • Phone: 714-683-2970
  • Fax: 714-683-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA89969
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: