Healthcare Provider Details

I. General information

NPI: 1023305687
Provider Name (Legal Business Name): MICHAEL TED BOLER JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 GLOSTER CREEK VLG STE A2
TUPELO MS
38801-4749
US

IV. Provider business mailing address

499 GLOSTER CREEK VLG STE A2
TUPELO MS
38801-4749
US

V. Phone/Fax

Practice location:
  • Phone: 662-620-6800
  • Fax: 662-620-6950
Mailing address:
  • Phone: 662-620-6800
  • Fax: 662-620-6950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number23370
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: