Healthcare Provider Details

I. General information

NPI: 1780113258
Provider Name (Legal Business Name): KATHERINE GRACE BOLTON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5629 STADIUM DR STE B
KALAMAZOO MI
49009-1952
US

IV. Provider business mailing address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

V. Phone/Fax

Practice location:
  • Phone: 269-544-3270
  • Fax:
Mailing address:
  • Phone: 269-337-6300
  • Fax: 269-337-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5151010665
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5101025468
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101025468
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: