Provider Demographics
NPI:1942939897
Name:BOSWORTH, KORA A (OD)
Entity type:Individual
Prefix:
First Name:KORA
Middle Name:A
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 JEFFERSON RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2019 JEFFERSON RD STE A
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3258
Practice Address - Country:US
Practice Address - Phone:507-645-9202
Practice Address - Fax:507-645-9203
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3786152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist