Provider Demographics
NPI:1730341918
Name:BOSTROM, CARA RHODES (MD)
Entity type:Individual
Prefix:
First Name:CARA
Middle Name:RHODES
Last Name:BOSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HAWTHORNE PARK CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3194
Mailing Address - Country:US
Mailing Address - Phone:864-603-5600
Mailing Address - Fax:
Practice Address - Street 1:9 HAWTHORNE PARK CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3194
Practice Address - Country:US
Practice Address - Phone:864-603-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25031207Q00000X
SC32279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC322799Medicaid
SCP01097627OtherRAILROAD MEDICARE
SC322799Medicaid