Provider Demographics
NPI:1164558854
Name:BOLTON, JONATHAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:W
Last Name:BOLTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF PSYCHIATRY
Practice Address - Street 2:2400 TUCKER, NE., MSC09 5030
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-3966
Practice Address - Fax:505-272-4639
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2007-01422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H00286Medicare UPIN
A30010Medicare ID - Type Unspecified