Provider Demographics
NPI:1215934740
Name:BOSTICK, PETER JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JAMES
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:J
Other - Last Name:BOSTICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14782
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70898-4782
Mailing Address - Country:US
Mailing Address - Phone:225-767-5520
Mailing Address - Fax:225-767-4934
Practice Address - Street 1:3401 NORTH BLVD
Practice Address - Street 2:STE 330
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-767-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12995R2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2193181OtherAETNA
LA1563471Medicaid
LA5E471Medicare ID - Type Unspecified
LA1563471Medicaid