Healthcare Provider Details

I. General information

NPI: 1144361411
Provider Name (Legal Business Name): WILLIAM K BOSTOCK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 JESSE JEWELL PKWY NE STE 102
GAINESVILLE GA
30501-3806
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-9445
  • Fax:
Mailing address:
  • Phone: 770-219-8721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number026458
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26458
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: