Basic Information
| Provider Information | |||||||||
| NPI: | 1407840895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSWORTH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 PLACER ST | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960011125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302465710 | ||||||||
| FaxNumber: | 5302447846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 PLACER ST | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960011125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302465710 | ||||||||
| FaxNumber: | 5302447846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G077006 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G770060 | 05 | CA | MEDICAID |