Healthcare Provider Details

I. General information

NPI: 1902998511
Provider Name (Legal Business Name): RICHARD GREGORY BOLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MS# 90
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

6430 W SUNSET BLVD SUITE 600
LOS ANGELES CA
90028-7901
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2178
  • Fax: 323-361-5937
Mailing address:
  • Phone: 323-361-2337
  • Fax: 323-361-8491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberG65717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: