MEDICARE: TIFFANY BOSWELL OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG001719	PA

General Provider Information

NPI Number	:	1073603023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY BOSWELL OD

Provider Business Mailing Address
First Line	:	9745 ROOSEVELT BLVD
Second Line	:	WALMART VISION CENTER
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1010
Country	:	US
Telephone Number	:	215-676-2425
Fax Number	:

Provider Business Practice Location Address
First Line	:	9745 ROOSEVELT BLVD
Second Line	:	WALMART VISION CENTER
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1010
Country	:	US
Telephone Number	:	215-676-2425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	08/03/2011

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