MEDICARE: ROBERT D BOSTICK JR. M.D.

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	2080A0000X	Pediatric Adolescent Medicine Physician	010641	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235130386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT D BOSTICK JR. M.D.

Provider Business Mailing Address
First Line	:	107 MARYLAND DRIVE
Second Line	:
City	:	LULING
State	:	LA
Zip	:	70070
Country	:	US
Telephone Number	:	504-349-6411
Fax Number	:	504-349-6415

Provider Business Practice Location Address
First Line	:	107 MARYLAND DRIVE
Second Line	:
City	:	LULING
State	:	LA
Zip	:	70070
Country	:	US
Telephone Number	:	504-349-6411
Fax Number	:	504-349-6415

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	05/20/2015

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