Basic Information
| Provider Information | |||||||||
| NPI: | 1982823951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSSOU | ||||||||
| FirstName: | KODJO | ||||||||
| MiddleName: | MARTIAL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550662848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | 51060 | MN | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 207Q00000X | 51060 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.