Provider Demographics
NPI:1801807144
Name:BOSEMAN, JERALD P (MD)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:P
Last Name:BOSEMAN
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 1:121 S OREM BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-3006
Mailing Address - Country:US
Mailing Address - Phone:801-225-4911
Mailing Address - Fax:801-225-4854
Practice Address - Street 1:121 S OREM BLVD STE 103
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-3006
Practice Address - Country:US
Practice Address - Phone:801-225-4911
Practice Address - Fax:801-225-4854
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48849207RN0300X
CO48108207RN0300X
UT5929764-1205207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29025354Medicaid
UT3007868Medicaid
MN055435000Medicaid
UT3007868Medicaid
CO29025354Medicaid