Healthcare Provider Details

I. General information

NPI: 1669415303
Provider Name (Legal Business Name): CHESTER MCBRIDE BOLTWOOD JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/13/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 DALE RD KAISER PERMANENTE MEDICAL OFFICES
MODESTO CA
95357-7680
US

IV. Provider business mailing address

4601 DALE RD
MODESTO CA
95356-9718
US

V. Phone/Fax

Practice location:
  • Phone: 209-735-4287
  • Fax: 209-735-4283
Mailing address:
  • Phone: 209-735-4287
  • Fax: 209-735-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG35042
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG35042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: