Provider Demographics
NPI:1730180704
Name:BOSANKO, CORY J (OD)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:J
Last Name:BOSANKO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 LANTANA RD
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4901
Mailing Address - Country:US
Mailing Address - Phone:931-484-3344
Mailing Address - Fax:931-456-3671
Practice Address - Street 1:39 LANTANA RD
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4901
Practice Address - Country:US
Practice Address - Phone:931-484-3344
Practice Address - Fax:931-456-3671
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000002541152WL0500X
TNOD2541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943261Medicaid
TN3946606Medicaid
TN4109506OtherBCBST
TN3946606Medicaid
TN3946606Medicare PIN
TN3943261Medicare PIN