Provider Demographics
NPI:1144295213
Name:BOSA-OSORIO, EDWIN (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:BOSA-OSORIO
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 1:4781 SW 86TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-8605
Mailing Address - Country:US
Mailing Address - Phone:786-245-2700
Mailing Address - Fax:
Practice Address - Street 1:3831 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4862
Practice Address - Country:US
Practice Address - Phone:786-245-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041775100Medicaid
FL34038XMedicare PIN
FL041775100Medicaid
FL34038YMedicare PIN