MEDICARE: JOSE A BOCANEGRA JR. M.D.

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	207Q00000X	Family Medicine Physician	35082489	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0007456582	OTHER	OH	AETNA PROVDER ID#
2	2479442	OTHER	OH	UNITED HEALTHCARE
3	1003087	OTHER	OH	QUALCHOICE
4	000000350199	OTHER	OH	ANTHEM BLUE CROSS BLUE SH

General Provider Information

NPI Number	:	1316033475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE A BOCANEGRA JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 638269
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-8269
Country	:	US
Telephone Number	:	440-816-2878
Fax Number	:

Provider Business Practice Location Address
First Line	:	10139 ROYALTON RD STE H
Second Line	:
City	:	NORTH ROYALTON
State	:	OH
Zip	:	44133-4473
Country	:	US
Telephone Number	:	440-816-2878
Fax Number	:

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	02/22/2022

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