Healthcare Provider Details

I. General information

NPI: 1356497101
Provider Name (Legal Business Name): DR. JACKIE A BOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6066 CIVIC TERRACE AVE
NEWARK CA
94560
US

IV. Provider business mailing address

PO BOX 10285
OAKLAND CA
94610
US

V. Phone/Fax

Practice location:
  • Phone: 510-505-1600
  • Fax: 510-494-7240
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberG57227
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: