Healthcare Provider Details

I. General information

NPI: 1538320577
Provider Name (Legal Business Name): JEFFREY P. BOLDUAN, M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 WINSTED DR STE 4
GOSHEN IN
46526-4673
US

IV. Provider business mailing address

1615 WINSTED DR STE 4
GOSHEN IN
46526-4673
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-8420
  • Fax: 574-533-3909
Mailing address:
  • Phone: 574-533-8420
  • Fax: 574-533-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01030767
License Number StateIN

VIII. Authorized Official

Name: DR. JEFFREY P BOLDUAN
Title or Position: PRESIDENT
Credential: MD
Phone: 574-533-8420