Provider Demographics
NPI:1437347929
Name:BOSTIC, DONALD MARK (PS-S)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:MARK
Last Name:BOSTIC
Suffix:
Gender:M
Credentials:PS-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:203 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-4208
Mailing Address - Country:US
Mailing Address - Phone:765-973-9294
Mailing Address - Fax:765-973-9233
Practice Address - Street 1:25 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:IN
Practice Address - Zip Code:47102-1303
Practice Address - Country:US
Practice Address - Phone:812-794-8100
Practice Address - Fax:812-794-8200
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2024-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10000954A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200490500AMedicaid
IN153883Medicare Oscar/Certification
IN218850CMedicare PIN