Provider Demographics
NPI:1922172311
Name:BOSTOCK, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BOSTOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:M. ELIZABETH
Other - Middle Name:
Other - Last Name:BOSTOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:990 SOUTH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2740
Mailing Address - Country:US
Mailing Address - Phone:585-232-3210
Mailing Address - Fax:585-232-4657
Practice Address - Street 1:990 SOUTH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2740
Practice Address - Country:US
Practice Address - Phone:585-232-3210
Practice Address - Fax:585-232-4657
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216055207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02283338Medicaid
NYDD6053Medicare ID - Type UnspecifiedMEDICARE I.D. NUMBER
NYH86869Medicare UPIN