Provider Demographics
NPI:1053394247
Name:BOSCH, LOURDES TERESA (MD)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:TERESA
Last Name:BOSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 NW LEJEUNE RD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-5683
Mailing Address - Country:US
Mailing Address - Phone:305-642-2600
Mailing Address - Fax:305-261-0603
Practice Address - Street 1:351 NW LEJEUNE RD
Practice Address - Street 2:SUITE 401
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5683
Practice Address - Country:US
Practice Address - Phone:305-642-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 43744207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053081600Medicaid
FL96557Medicare ID - Type Unspecified
FL053081600Medicaid