Provider Demographics
NPI:1295936961
Name:BOSWELL, JOHN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:BOSWELL
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 1:6730 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-4301
Mailing Address - Country:US
Mailing Address - Phone:559-439-3000
Mailing Address - Fax:559-439-3004
Practice Address - Street 1:6730 N WEST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-4301
Practice Address - Country:US
Practice Address - Phone:559-439-3000
Practice Address - Fax:559-439-3004
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100542207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1005420OtherBLUE SHIELD
CACD009XMedicare PIN