1477575009 NPI number — MRS. LESLIE LUIDA BOSTICK PEDIATRICS MD

Table of content: MRS. LESLIE LUIDA BOSTICK PEDIATRICS MD (NPI 1477575009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477575009 NPI number — MRS. LESLIE LUIDA BOSTICK PEDIATRICS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSTICK
Provider First Name:
LESLIE
Provider Middle Name:
LUIDA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PEDIATRICS MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
LESLIE
Provider Other Middle Name:
LUIDA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1477575009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14782
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-767-5520
Provider Business Mailing Address Fax Number:
225-767-4934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8595 PICARDY AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-3670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-767-5520
Provider Business Practice Location Address Fax Number:
225-767-4934
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  12994R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2211737 . This is a "AETNA (HOM)" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 5402322 . This is a "AETNA (POS)" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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