MEDICARE: KYLE BOLTSON

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	207Q00000X	Family Medicine Physician	OS20226	FL

General Provider Information

NPI Number	:	1790363158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE BOLTSON

Provider Business Mailing Address
First Line	:	6101 BLUE LAGOON DR STE 200
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-3168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 SE HILLMOOR DR STE 500
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-7536
Country	:	US
Telephone Number	:	772-873-1770
Fax Number	:

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

Provider Enumeration Date	:	03/29/2021
Last Update Date	:	10/10/2025

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Directions to “ KYLE BOLTSON ” Practice Location

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