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General NPI Number Information
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NPI Number | 1144251067
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Entity Type | Individual
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Provider Name | SAMUEL ANTONIO BOLIVAR MD
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Gender | Male
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 04/27/2023
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Provider Practice Location Address
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Address Line | 555 N D ST SUITE 130
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City | SAN BERNARDINO
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State | CA
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Zip | 92401-1305
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Country | US
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Telephone | 909-888-8154
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Fax | 909-888-9940
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Provider Business Mailing Address
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Address Line | 3410 LA SIERRA AVE # F369
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City | RIVERSIDE
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State | CA
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Zip | 92503-5270
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Country | US
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Telephone | 909-888-8154
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Fax | 909-888-9940
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A41590
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License Number State | CA
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