Provider Demographics
NPI:1174502314
Name:BOLAN, PETER J (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:BOLAN
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 1:836 PRUDENTIAL DRIVE, STE 1804
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8345
Mailing Address - Country:US
Mailing Address - Phone:904-398-3888
Mailing Address - Fax:904-400-6675
Practice Address - Street 1:836 PRUDENTIAL DRIVE, STE 1804
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8345
Practice Address - Country:US
Practice Address - Phone:904-398-3888
Practice Address - Fax:904-400-6675
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME162343208G00000X
GA40825208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA514167426AMedicaid
GA77BBBFTMedicare ID - Type Unspecified
GA514167426AMedicaid