Provider Demographics
NPI:1104823491
Name:BOLUS, DAVID NORMAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:NORMAN
Last Name:BOLUS
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5000
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195
Practice Address - Country:US
Practice Address - Phone:206-520-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD608493722085R0202X
AL139112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1104823491Medicaid
AL009995720Medicaid
ALP00653193OtherRAILROAD MEDICARE
MS00773370Medicaid
AL051591977OtherBCBS
AL51510655OtherBLUE CROSS BLUE SHIELD AL
AL510I300105Medicare PIN
AL510I300156Medicare PIN
ALP00653193OtherRAILROAD MEDICARE
MS00773370Medicaid
AL103094Medicaid
AL009995720Medicaid
ALE20738Medicare UPIN