Healthcare Provider Details

I. General information

NPI: 1912909581
Provider Name (Legal Business Name): MARY ELIZABETH BOLTON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S MAIN ST SUITE 1
CHAGRIN FALLS OH
44022-3225
US

IV. Provider business mailing address

1 S MAIN ST SUITE 1
CHAGRIN FALLS OH
44022-3225
US

V. Phone/Fax

Practice location:
  • Phone: 440-893-8800
  • Fax: 440-893-9422
Mailing address:
  • Phone: 440-893-8800
  • Fax: 440-893-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36 002693
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: