Healthcare Provider Details

I. General information

NPI: 1164575205
Provider Name (Legal Business Name): DR. DAVID B BOSTICK III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 HOSPITAL ST
CADIZ KY
42211-7970
US

IV. Provider business mailing address

13 HOSPITAL ST P.O. BOX 326
CADIZ KY
42211-7970
US

V. Phone/Fax

Practice location:
  • Phone: 270-522-1234
  • Fax:
Mailing address:
  • Phone: 270-522-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1028DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: