Provider Demographics
NPI:1962899971
Name:BOSTON, DAKOTA (MD)
Entity type:Individual
Prefix:
First Name:DAKOTA
Middle Name:
Last Name:BOSTON
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 1:2449 HOSPITAL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-1914
Mailing Address - Country:US
Mailing Address - Phone:182-127-9023
Mailing Address - Fax:318-212-7905
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP STE 480
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5765
Practice Address - Country:US
Practice Address - Phone:318-212-2810
Practice Address - Fax:318-212-2818
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.307727207RE0101X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2387928Medicaid