Healthcare Provider Details

I. General information

NPI: 1417019019
Provider Name (Legal Business Name): RICHARD M BOSSIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 NORTH CAPITOL STREET NE
WASHINGTON DC
20002-4236
US

IV. Provider business mailing address

2101 EAST JEFFERSON STREET PPQA MEDICARE COMP. UNIT 6 KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 202-898-5104
  • Fax: 202-898-5474
Mailing address:
  • Phone: 301-816-6660
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0P1000115
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000015
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: