Healthcare Provider Details

I. General information

NPI: 1265616007
Provider Name (Legal Business Name): KELLY MICHELLE BOLDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 WISCONSIN AVE NW STE 100
WASHINGTON DC
20015-2070
US

IV. Provider business mailing address

4834 BLAGDEN AVE NW
WASHINGTON DC
20011-3716
US

V. Phone/Fax

Practice location:
  • Phone: 202-237-9292
  • Fax:
Mailing address:
  • Phone: 202-230-0364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberD0071243
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD040080
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: