Provider Demographics
NPI:1063507382
Name:BOLDY, ROBERT MATHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MATHEW
Last Name:BOLDY
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 1:18077 US HIGHWAY 18 STE 100
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2168
Mailing Address - Country:US
Mailing Address - Phone:760-946-8169
Mailing Address - Fax:
Practice Address - Street 1:18077 US HIGHWAY 18 STE 100
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2168
Practice Address - Country:US
Practice Address - Phone:760-946-8169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2186207R00000X
CAG80969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BX469OtherBLUE CROSS, BLUE SHIELD
TX8L7866Medicare PIN