Healthcare Provider Details

I. General information

NPI: 1093020893
Provider Name (Legal Business Name): JOSHUA E. BOSTICK, O.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 WILLOWBROOK DR
SALTILLO MS
38866-6895
US

IV. Provider business mailing address

122 WILLOWBROOK DR
SALTILLO MS
38866-6895
US

V. Phone/Fax

Practice location:
  • Phone: 662-869-1779
  • Fax: 662-869-3776
Mailing address:
  • Phone: 662-869-1779
  • Fax: 662-869-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number821
License Number StateMS

VIII. Authorized Official

Name: DR. JOSHUA EDWIN BOSTICK
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 662-869-1779