Healthcare Provider Details

I. General information

NPI: 1124645403
Provider Name (Legal Business Name): AUSTIN BOLKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W 10TH AVE 368 DOAN HALL
COLUMBUS OH
43210
US

IV. Provider business mailing address

410 W 10TH AVE 368 DOAN HALL
COLUMBUS OH
43210-1240
US

V. Phone/Fax

Practice location:
  • Phone: 614-685-5805
  • Fax:
Mailing address:
  • Phone: 614-685-5805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number58.035335
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03439710
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: