=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104958156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS LEE BOSSHARDT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 12/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 E CHURCH ST STE 202
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93454-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-346-3456
-----------------------------------------------------
Fax | 805-346-3454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1325 E CHURCH ST STE 202
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93454-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-346-3456
-----------------------------------------------------
Fax | 805-346-3454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | G78405
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------