Provider Demographics
NPI:1063462018
Name:BOLGAR, GARY C (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:BOLGAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 DORCHESTER AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5628
Mailing Address - Country:US
Mailing Address - Phone:617-298-2075
Mailing Address - Fax:617-298-0727
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:617-298-2075
Practice Address - Fax:617-298-0727
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA047797208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2096501Medicaid
MA2096501Medicaid
A66487Medicare UPIN