Healthcare Provider Details

I. General information

NPI: 1811638851
Provider Name (Legal Business Name): MATTHEW GORDON BOLIAUX DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 N 3RD AVE STE 470
PHOENIX AZ
85013-4434
US

IV. Provider business mailing address

240 W THOMAS RD # 301
PHOENIX AZ
85013-4407
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-6262
  • Fax: 602-406-6261
Mailing address:
  • Phone: 602-406-6262
  • Fax: 602-406-6261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number012497
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: