Provider Demographics
NPI:1033184205
Name:BOLON, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 GREENWICH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-2047
Mailing Address - Country:US
Mailing Address - Phone:646-279-0688
Mailing Address - Fax:877-409-1860
Practice Address - Street 1:133 E 58TH ST STE 1402
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1236
Practice Address - Country:US
Practice Address - Phone:646-705-0035
Practice Address - Fax:877-409-1860
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208240207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01-0597943OtherTAX ID
NY059AIJ7021Medicare PIN
NYH62397Medicare UPIN