Provider Demographics
NPI:1407832306
Name:BOSTOCK, DEBORAH JEAN (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:BOSTOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:JEAN
Other - Last Name:HERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1345 RXR PLZ
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-783-4600
Mailing Address - Fax:646-846-3283
Practice Address - Street 1:315 W 57TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3158
Practice Address - Country:US
Practice Address - Phone:212-315-2330
Practice Address - Fax:212-682-9304
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD19935207Q00000X
VA0101241804207QG0300X
NY286649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine