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General NPI Number Information
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NPI Number | 1205067188
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Entity Type | Organization
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Legal Business Name | GARY G. BOLTON, M. D., P. A.
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Dates
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Enumeration Date | 07/27/2009
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Last Update Date | 07/27/2009
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Provider Practice Location Address
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Address Line | 305 HIGHLAND PARK COVE
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City | RIDGELAND
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State | MS
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Zip | 39157-6059
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Country | US
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Telephone | 601-206-9433
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Fax |
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Provider Business Mailing Address
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Address Line | 305 HIGHLAND PARK COVE
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City | RIDGELAND
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State | MS
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Zip | 39157-6059
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY G BOLTON
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Credential | M. D.
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Telephone | 601-206-9433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 10243
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License Number State | MS
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