Provider Demographics
NPI:1114644481
Name:BOLANOS, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:BOLANOS
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 1:2 RICHMOND SQ STE 110
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5135
Mailing Address - Country:US
Mailing Address - Phone:401-414-1400
Mailing Address - Fax:401-414-1401
Practice Address - Street 1:2 RICHMOND SQ STE 110
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5135
Practice Address - Country:US
Practice Address - Phone:401-414-1400
Practice Address - Fax:401-414-1401
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program