Healthcare Provider Details

I. General information

NPI: 1518055441
Provider Name (Legal Business Name): JOE RANDOLPH BOLTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 E HERNDON AVE #104
FRESNO CA
93720-3022
US

IV. Provider business mailing address

1377 E HERNDON AVE #104
FRESNO CA
93720-3022
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-7455
  • Fax: 559-450-7473
Mailing address:
  • Phone: 559-450-7455
  • Fax: 559-450-7473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberJ3436
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG88027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: