Provider Demographics
NPI:1144251067
Name:BOLIVAR, SAMUEL ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ANTONIO
Last Name:BOLIVAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3410 LA SIERRA AVE # F369
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5270
Mailing Address - Country:US
Mailing Address - Phone:909-888-8154
Mailing Address - Fax:909-888-9940
Practice Address - Street 1:555 N D ST
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1305
Practice Address - Country:US
Practice Address - Phone:909-888-8154
Practice Address - Fax:909-888-9940
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA41590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A415900Medicaid
CA00A415900Medicare PIN
CA00A415900Medicaid