Provider Demographics
NPI:1477575009
Name:BOSTICK, LESLIE LUIDA (PEDIATRICS MD)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:LUIDA
Last Name:BOSTICK
Suffix:
Gender:F
Credentials:PEDIATRICS MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:LUIDA
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14782
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70898
Mailing Address - Country:US
Mailing Address - Phone:225-767-5520
Mailing Address - Fax:225-767-4934
Practice Address - Street 1:8595 PICARDY AVE
Practice Address - Street 2:STE 200
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3670
Practice Address - Country:US
Practice Address - Phone:225-767-5520
Practice Address - Fax:225-767-4934
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12994R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2211737OtherAETNA (HOM)
LA5402322OtherAETNA (POS)
F36192Medicare UPIN
LA2211737OtherAETNA (HOM)