Healthcare Provider Details

I. General information

NPI: 1548233166
Provider Name (Legal Business Name): JOANNA GRACE BOLTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 OLD CAMP RD
THE VILLAGES FL
32162-1762
US

IV. Provider business mailing address

8620 E COUNTY ROAD 466
THE VILLAGES FL
32162-3670
US

V. Phone/Fax

Practice location:
  • Phone: 352-399-7295
  • Fax: 352-399-7294
Mailing address:
  • Phone: 352-399-7295
  • Fax: 352-399-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME128472
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: