Provider Demographics
NPI:1184937690
Name:BOSTICK, JOSHUA EDWIN (OD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:EDWIN
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:OD
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 1055
Mailing Address - Street 2:107 TOWN CREEK DRIVE
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-1055
Mailing Address - Country:US
Mailing Address - Phone:662-869-1779
Mailing Address - Fax:
Practice Address - Street 1:107 TOWN CREEK DR
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-7947
Practice Address - Country:US
Practice Address - Phone:662-869-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07622573Medicaid
MS302G414318Medicare UPIN
MS07622573Medicaid