Provider Demographics
NPI:1063454064
Name:BOLTE, ROBERT G (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:BOLTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:295 CHIPETA WAY
Mailing Address - Street 2:PEDS ADMIN
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1220
Mailing Address - Country:US
Mailing Address - Phone:801-587-7400
Mailing Address - Fax:801-587-7417
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-2233
Practice Address - Fax:801-588-2236
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-05-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT165008-1205208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002085363Medicaid
ID003594800Medicaid
MT0142664Medicaid
LA1172456Medicaid
UT06395Medicaid
WY121338500Medicaid
LA1172456Medicaid
UTF14628Medicare UPIN