Healthcare Provider Details

I. General information

NPI: 1164558854
Provider Name (Legal Business Name): JONATHAN W. BOLTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF PSYCHIATRY 2400 TUCKER, NE., MSC09 5030
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3966
  • Fax: 505-272-4639
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2007-0142
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: