Healthcare Provider Details

I. General information

NPI: 1255925939
Provider Name (Legal Business Name): SHUBHRO BOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-4789
  • Fax: 210-916-6654
Mailing address:
  • Phone: 571-231-3224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberU0967
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: