Healthcare Provider Details

I. General information

NPI: 1932184181
Provider Name (Legal Business Name): TRAVIS L BOLTON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE
RIO RANCHO NM
87124-4740
US

IV. Provider business mailing address

5410 MARYLAND WAY STE 300
BRENTWOOD TN
37027-5339
US

V. Phone/Fax

Practice location:
  • Phone: 505-253-1187
  • Fax: 505-253-1199
Mailing address:
  • Phone: 615-371-5778
  • Fax: 615-290-5294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2017-0672
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD2017-0672
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: