Healthcare Provider Details

I. General information

NPI: 1831278027
Provider Name (Legal Business Name): JEFFREY P BOLDUAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 CHARLTON CT
GOSHEN IN
46526-6463
US

IV. Provider business mailing address

1808 CHARLTON CT
GOSHEN IN
46526-6463
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:
Title or Position:
Credential:
Phone: