Healthcare Provider Details

I. General information

NPI: 1912032962
Provider Name (Legal Business Name): THEODORE R BOSCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 S 14TH ST
MOUNT VERNON WA
98274-4117
US

IV. Provider business mailing address

1415 E KINCAID ST
MOUNT VERNON WA
98274-4126
US

V. Phone/Fax

Practice location:
  • Phone: 360-814-2600
  • Fax:
Mailing address:
  • Phone: 360-428-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD61652294
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: