Provider Demographics
NPI:1033551437
Name:BOSTIAN, ELISSA (OD)
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:
Last Name:BOSTIAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 S GUTENSOHN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5228
Mailing Address - Country:US
Mailing Address - Phone:479-750-3937
Mailing Address - Fax:479-750-3943
Practice Address - Street 1:1600 W SUNSET AVE STE A
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-5223
Practice Address - Country:US
Practice Address - Phone:479-756-1234
Practice Address - Fax:479-756-1180
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist