Healthcare Provider Details

I. General information

NPI: 1053390021
Provider Name (Legal Business Name): JONATHAN WYATT BOLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

8960 W TROPICANA AVE STE 100
LAS VEGAS NV
89147-8161
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-6949
  • Fax:
Mailing address:
  • Phone: 702-379-5234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number10584
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-129158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: