Healthcare Provider Details

I. General information

NPI: 1659348514
Provider Name (Legal Business Name): GARY DOUGLAS BOZEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 W BROADWAY
FULTON NY
13069-1533
US

IV. Provider business mailing address

1226 E WATER ST
SYRACUSE NY
13210-1155
US

V. Phone/Fax

Practice location:
  • Phone: 315-297-4700
  • Fax: 315-218-5898
Mailing address:
  • Phone: 315-478-4185
  • Fax: 315-478-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number272579
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier153372
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: