1487635462 NPI number — EDGAR B BOLTON JR. DO

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	BOLTON
Provider First Name	:	EDGAR
Provider Middle Name	:	B
Provider Name Prefix Text	:
Provider Name Suffix Text	:	JR.
Provider Credential Text	:	DO
Provider Gender Code	:	M

Provider Other Organization Name	:
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Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
Provider Other Name Prefix Text	:
Provider Other Name Suffix Text	:
Provider Other Credential Text	:
Provider Other Last Name Type Code	:

NPI Number	:	1487635462
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	11/17/2009
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
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Provider First Line Business Mailing Address	:	7369 SHERIDAN ST
Provider Second Line Business Mailing Address	:	STE 302
Provider Business Mailing Address City Name	:	HOLLYWOOD
Provider Business Mailing Address State Name	:	FL
Provider Business Mailing Address Postal Code	:	330242776
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	9549813700
Provider Business Mailing Address Fax Number	:	9549874414

Provider First Line Business Practice Location Address	:	7369 SHERIDAN ST
Provider Second Line Business Practice Location Address	:	STE 302
Provider Business Practice Location Address City Name	:	HOLLYWOOD
Provider Business Practice Location Address State Name	:	FL
Provider Business Practice Location Address Postal Code	:	330242776
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	9549813700
Provider Business Practice Location Address Fax Number	:	9549874414
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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Authorized Official Telephone Number	:

• Taxonomy code: 207RP1001X , with the licence number:  OS2458 , registered in the state of FL .

• Identifier: E12175 . This identifiers is of the category "".
• Identifier: 037708200 , issued by the state of ( FL ) . This identifiers is of the category "".
• Identifier: 81981 . This identifiers is of the category "".