MEDICARE: MARC RICHARD BOSTIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225000000X	Orthotic Fitter

General Provider Information

NPI Number	:	1053559310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARC RICHARD BOSTIAN

Provider Business Mailing Address
First Line	:	3545 NW 58TH ST STE 330
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4718
Country	:	US
Telephone Number	:	405-819-3241
Fax Number	:

Provider Business Practice Location Address
First Line	:	3545 NW 58TH ST STE 330
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4718
Country	:	US
Telephone Number	:	405-819-3241
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2009
Last Update Date	:	01/25/2009

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