Healthcare Provider Details

I. General information

NPI: 1255342358
Provider Name (Legal Business Name): DAVID L BOLES SR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 HIGHWAY 76 STE A
CLARKSVILLE TN
37043-2531
US

IV. Provider business mailing address

PO BOX 30459
CLARKSVILLE TN
37040
US

V. Phone/Fax

Practice location:
  • Phone: 931-245-1150
  • Fax: 931-245-0605
Mailing address:
  • Phone: 931-245-1150
  • Fax: 931-245-0605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO647
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: