Healthcare Provider Details

I. General information

NPI: 1073019261
Provider Name (Legal Business Name): BRANDON FORREST BOLDT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 KOLLMEYER ST
NEWPORT RI
02841-1605
US

IV. Provider business mailing address

43 SMITH RD
NEWPORT RI
02841-1006
US

V. Phone/Fax

Practice location:
  • Phone: 401-841-7987
  • Fax:
Mailing address:
  • Phone: 401-841-7987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMD-46469
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: