Provider Demographics
NPI:1164575205
Name:BOSTICK, DAVID B III
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:BOSTICK
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 HOSPITAL ST
Mailing Address - Street 2:P.O. BOX 326
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-7970
Mailing Address - Country:US
Mailing Address - Phone:270-522-1234
Mailing Address - Fax:
Practice Address - Street 1:13 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-7970
Practice Address - Country:US
Practice Address - Phone:270-522-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1028DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010288Medicaid
KY77010288Medicaid
KY0132400001Medicare NSC
KY9209601Medicare PIN