Provider Demographics
NPI:1164457099
Name:BOLKHOVSKY, ALLA (MD)
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:BOLKHOVSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1215
Mailing Address - Country:US
Mailing Address - Phone:508-481-5500
Mailing Address - Fax:508-460-3221
Practice Address - Street 1:761 WORCESTER RD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-5224
Practice Address - Country:US
Practice Address - Phone:508-872-3254
Practice Address - Fax:508-879-7910
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50367207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3038939Medicaid
MA3038939Medicaid
MAJ07140Medicare ID - Type Unspecified