Provider Demographics
NPI:1063439586
Name:BOSTIC, OSWALD (MD)
Entity type:Individual
Prefix:
First Name:OSWALD
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27177 LAHSER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-4714
Mailing Address - Country:US
Mailing Address - Phone:248-357-1360
Mailing Address - Fax:248-357-2610
Practice Address - Street 1:27177 LAHSER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4714
Practice Address - Country:US
Practice Address - Phone:248-357-1360
Practice Address - Fax:248-357-2610
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032284174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1119030Medicaid
MI0F36161Medicare ID - Type Unspecified
MI1119030Medicaid