Provider Demographics
NPI:1295886125
Name:BOSTROM, JAKE P (MD)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:P
Last Name:BOSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 HEYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1726
Mailing Address - Country:US
Mailing Address - Phone:864-583-6381
Mailing Address - Fax:864-583-6390
Practice Address - Street 1:1520 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:SC
Practice Address - Zip Code:29316
Practice Address - Country:US
Practice Address - Phone:864-583-6381
Practice Address - Fax:864-583-6390
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31615207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA3955-7292OtherMEDICARE PTAN
SC31615OtherSC LICENSE
SC1457384729OtherGROUP NPI
SC316152Medicaid
SCP01501403OtherRR MEDICARE
SCAA39556180OtherMEDICARE PTAN
SC31615OtherSC LICENSE