Healthcare Provider Details

I. General information

NPI: 1942696562
Provider Name (Legal Business Name): GARY C BOSSHARDT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 NORTHFIELD RD STE 301
CEDAR CITY UT
84721
US

IV. Provider business mailing address

1251 NORTHFIELD RD STE 301
CEDAR CITY UT
84721-8625
US

V. Phone/Fax

Practice location:
  • Phone: 435-865-7227
  • Fax:
Mailing address:
  • Phone: 435-865-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6878938-1205
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: