Healthcare Provider Details

I. General information

NPI: 1184640088
Provider Name (Legal Business Name): DAVID HENRY BOLONKIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2818 GRANT LINE RD
NEW ALBANY IN
47150-2492
US

IV. Provider business mailing address

734 W MAIN ST STE 100
LOUISVILLE KY
40202-3687
US

V. Phone/Fax

Practice location:
  • Phone: 812-725-7542
  • Fax: 812-725-7543
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000563
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: