Healthcare Provider Details

I. General information

NPI: 1740923937
Provider Name (Legal Business Name): MATTHEW EDWARD BOLERJACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7130 MIRAMAR RD STE 400
SAN DIEGO CA
92121-2340
US

IV. Provider business mailing address

6879 OROLA LN
LA MESA CA
91942-4525
US

V. Phone/Fax

Practice location:
  • Phone: 619-609-3171
  • Fax:
Mailing address:
  • Phone: 619-609-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number104470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: