Healthcare Provider Details

I. General information

NPI: 1790785152
Provider Name (Legal Business Name): MARK JAMES BOLTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N JAMES RD
COLUMBUS OH
43219-1834
US

IV. Provider business mailing address

8703 BELWORTH SQ
NEW ALBANY OH
43054-9074
US

V. Phone/Fax

Practice location:
  • Phone: 614-257-5000
  • Fax:
Mailing address:
  • Phone: 614-313-6112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number69133
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69133
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number69133
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: