Provider Demographics
NPI:1235130386
Name:BOSTICK, ROBERT D JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:BOSTICK
Suffix:JR
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 1:107 MARYLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070
Mailing Address - Country:US
Mailing Address - Phone:504-349-6411
Mailing Address - Fax:504-349-6415
Practice Address - Street 1:107 MARYLAND DRIVE
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070
Practice Address - Country:US
Practice Address - Phone:504-349-6411
Practice Address - Fax:504-349-6415
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0106412080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1118796Medicaid
LAF84394Medicare UPIN
LA5M297Medicare PIN
LA381503ZK07Medicare PIN