Provider Demographics
NPI:1144399619
Name:BOSTICK-SMITH, CHEVELTA A (DO)
Entity Type:Individual
Prefix:
First Name:CHEVELTA
Middle Name:A
Last Name:BOSTICK-SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 S MAYHILL RD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-5910
Mailing Address - Country:US
Mailing Address - Phone:940-591-6700
Mailing Address - Fax:940-320-1220
Practice Address - Street 1:2805 S MAYHILL RD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-5910
Practice Address - Country:US
Practice Address - Phone:940-591-6700
Practice Address - Fax:940-320-1220
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016822207V00000X
DEC2-0008113207V00000X
NJ25MB07958800207V00000X
TXQ7326207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0154750Medicaid
PA1028777090006Medicaid
PA335173US8Medicare UPIN
NJ117135AEEMedicare PIN