Provider Demographics
NPI:1184005365
Name:BOLTRON, GAIL (DO)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:BOLTRON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9003 PRINCETON WAY
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4639
Mailing Address - Country:US
Mailing Address - Phone:714-906-4218
Mailing Address - Fax:
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-5073
Practice Address - Country:US
Practice Address - Phone:520-694-7432
Practice Address - Fax:520-694-6688
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-14
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR2487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics