Healthcare Provider Details

I. General information

NPI: 1831195767
Provider Name (Legal Business Name): KENNETH BOSSLET D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 FAIRINGTON DR
SIDNEY OH
45365-8144
US

IV. Provider business mailing address

1205 FAIRINGTON DR
SIDNEY OH
45365-8144
US

V. Phone/Fax

Practice location:
  • Phone: 937-492-8431
  • Fax: 937-498-5126
Mailing address:
  • Phone: 937-492-8431
  • Fax: 937-498-5126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4719
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: