Provider Demographics
NPI:1962416149
Name:BOSTAPH, KEITH L (DC)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:BOSTAPH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6053 SPINNAKER LOOP
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-5922
Mailing Address - Country:US
Mailing Address - Phone:352-638-9090
Mailing Address - Fax:352-638-9092
Practice Address - Street 1:6053 SPINNAKER LOOP
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-5922
Practice Address - Country:US
Practice Address - Phone:352-638-9090
Practice Address - Fax:352-638-9092
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004450700Medicaid
FL70100OtherBCBS
70100YMedicare ID - Type Unspecified
FL004450700Medicaid