Healthcare Provider Details

I. General information

NPI: 1285642330
Provider Name (Legal Business Name): DEWITT L BOLTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 SIXTH AVE
PICAYUNE MS
39466-3802
US

IV. Provider business mailing address

906 SIXTH AVE
PICAYUNE MS
39466-3802
US

V. Phone/Fax

Practice location:
  • Phone: 601-798-7529
  • Fax: 601-798-7553
Mailing address:
  • Phone: 601-798-7529
  • Fax: 601-798-7553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05036
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: