Provider Demographics
NPI:1730121823
Name:BOSTIC, BROOKE A (MD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:BOSTIC
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:PO BOX 79777
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0777
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-985-7848
Practice Address - Street 1:140 STONERIDGE DR S STE 100
Practice Address - Street 2:
Practice Address - City:RUCKERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22968
Practice Address - Country:US
Practice Address - Phone:434-654-1850
Practice Address - Fax:434-985-7848
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00466766Medicare PIN
VAF68566Medicare UPIN
VA016154M54Medicare PIN