Healthcare Provider Details

I. General information

NPI: 1073141362
Provider Name (Legal Business Name): JAMES LAWRENCE BOLDUC DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E OAK ST
KISSIMMEE FL
34744-5838
US

IV. Provider business mailing address

PO BOX 420037
KISSIMMEE FL
34742-0037
US

V. Phone/Fax

Practice location:
  • Phone: 321-442-8009
  • Fax: 321-442-8012
Mailing address:
  • Phone: 321-442-8009
  • Fax: 321-442-8012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS22508
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS22508
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberOS22508
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: