1508992470 NPI number — DR. LUKE BOLEK MD

Table of content: DR. LUKE BOLEK MD (NPI 1508992470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508992470 NPI number — DR. LUKE BOLEK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLEK
Provider First Name:
LUKE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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 Information

NPI Number:
1508992470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 232410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92193-2410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8932 SW 97H AVE
Provider Second Line Business Practice Location Address:
SOUTH WING
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33176-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-243-5512
Provider Business Practice Location Address Fax Number:
305-243-4613
Provider Enumeration Date:
02/26/2007

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: 207U00000X , with the licence number:  ME98885 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME98885 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0314542 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 279088200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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