Provider Demographics
NPI:1326087354
Name:BUNDRICK, WILLIAM STEWART JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:STEWART
Last Name:BUNDRICK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:STEWART
Other - Middle Name:
Other - Last Name:BUNDRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2449 HOSPITAL DR
Mailing Address - Street 2:SUITE 280
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2394
Mailing Address - Country:US
Mailing Address - Phone:318-841-4004
Mailing Address - Fax:318-841-4008
Practice Address - Street 1:2449 HOSPITAL DR
Practice Address - Street 2:SUITE 280
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2399
Practice Address - Country:US
Practice Address - Phone:318-841-4004
Practice Address - Fax:318-841-4008
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020454208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1397571Medicaid
LA5N988CP05Medicare PIN
LAF72811Medicare UPIN