MEDICARE: DR. ROBERT KEY BOLAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	G39301	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G39301	OTHER	CA	STATE LICENSE #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386643831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT KEY BOLAN M.D.

Provider Business Mailing Address
First Line	:	1625 SCHRADER BLVD FL 3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-6213
Country	:	US
Telephone Number	:	323-993-7500
Fax Number	:	323-308-4015

Provider Business Practice Location Address
First Line	:	1625 SCHRADER BLVD
Second Line	:	3RD FLOOR
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-6213
Country	:	US
Telephone Number	:	323-993-7500
Fax Number	:	323-308-4015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	02/08/2018

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