Provider Demographics
NPI:1073761128
Name:BOLTON, BRIAN DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DANIEL
Last Name:BOLTON
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 1:303 E CHICAGO AVE
Mailing Address - Street 2:WARD6-204
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4296
Mailing Address - Country:US
Mailing Address - Phone:312-503-8144
Mailing Address - Fax:
Practice Address - Street 1:303 E CHICAGO AVE
Practice Address - Street 2:WARD6-204
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4296
Practice Address - Country:US
Practice Address - Phone:312-503-8144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049094207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology