Provider Demographics
NPI:1477829125
Name:BOSTICK, DAVID S (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:BOSTICK
Suffix:
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 1:86 W UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:321-843-5270
Mailing Address - Fax:321-843-5177
Practice Address - Street 1:86 W UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:321-843-5270
Practice Address - Fax:321-843-5177
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME136356207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024873900Medicaid