Provider Demographics
NPI:1093459992
Name:BOSTIC, MORGAN TAYLOR (OD)
Entity type:Individual
Prefix:DR
First Name:MORGAN
Middle Name:TAYLOR
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MORGAN
Other - Middle Name:TAYLOR
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1451 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-8421
Mailing Address - Country:US
Mailing Address - Phone:330-205-5022
Mailing Address - Fax:
Practice Address - Street 1:1275 GLEN DR
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:OH
Practice Address - Zip Code:44654-8958
Practice Address - Country:US
Practice Address - Phone:330-674-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH007039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0492706Medicaid