Provider Demographics
NPI:1174502009
Name:BOLD, EDWARD JAY (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JAY
Last Name:BOLD
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 1:3701 SKYPARK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4749
Mailing Address - Country:US
Mailing Address - Phone:310-378-8900
Mailing Address - Fax:310-791-0786
Practice Address - Street 1:3701 SKYPARK DR
Practice Address - Street 2:STE 200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4749
Practice Address - Country:US
Practice Address - Phone:310-378-8900
Practice Address - Fax:310-791-0786
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38189207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G115630Medicaid
QG11563CMedicare ID - Type Unspecified
CAWG11563CMedicare PIN
CA00G115630Medicaid