=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457524704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT L BOLTUCH DOPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2008
-----------------------------------------------------
Last Update Date | 04/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2695 N MILITARY TRL SUITE # 17
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-2974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-689-2110
-----------------------------------------------------
Fax | 561-689-2032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2695 N MILITARY TRL SUITE # 17
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-2974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-689-2110
-----------------------------------------------------
Fax | 561-689-2032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINSTRATOR
-----------------------------------------------------
Name | MRS. SINTRA BOLTUCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-689-2110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS0004902
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------