Provider Demographics
NPI:1881672418
Name:BOST, ROGER KINGSLEY (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:KINGSLEY
Last Name:BOST
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 220
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902
Mailing Address - Country:US
Mailing Address - Phone:573-686-2411
Mailing Address - Fax:573-686-8452
Practice Address - Street 1:686 LESTER ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-686-2411
Practice Address - Fax:573-686-8452
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101937208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103885001Medicaid
MO203450408Medicaid
AR103885001Medicaid
000005377Medicare ID - Type Unspecified
D84076Medicare UPIN