Provider Demographics
NPI:1164482998
Name:BOLICK, VERONICA (NP)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:BOLICK
Suffix:
Gender:F
Credentials:NP
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 708850
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-8850
Mailing Address - Country:US
Mailing Address - Phone:866-869-2395
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:6644 E BAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1747
Practice Address - Country:US
Practice Address - Phone:480-981-4391
Practice Address - Fax:480-981-4624
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN061339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ366288Medicaid
AZ102165Medicare PIN
AZS72087Medicare UPIN
AZZ78253Medicare ID - Type Unspecified
AZ102131Medicare PIN
AZ36628802Medicare ID - Type Unspecified
AZ366288Medicaid