Healthcare Provider Details

I. General information

NPI: 1013119650
Provider Name (Legal Business Name): ANGELA DENE BOLZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 E 36TH ST N
TULSA OK
74106-1812
US

IV. Provider business mailing address

4502 E 41ST ST
TULSA OK
74135-2536
US

V. Phone/Fax

Practice location:
  • Phone: 918-619-4400
  • Fax: 918-619-4591
Mailing address:
  • Phone: 918-619-4400
  • Fax: 918-619-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4505
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: