Healthcare Provider Details

I. General information

NPI: 1013750215
Provider Name (Legal Business Name): MADISON LEE BOLIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BRYAN DR STE 201
DURANT OK
74701-2157
US

IV. Provider business mailing address

1400 BRYAN DR STE 201
DURANT OK
74701-2157
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-5500
  • Fax:
Mailing address:
  • Phone: 580-924-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1123R
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: