Provider Demographics
NPI:1215372263
Name:BOLTON, KELLY LEIGH (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LEIGH
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-8304
Mailing Address - Fax:314-454-5902
Practice Address - Street 1:1 BARNES JEWISH HOSPITAL PLZ
Practice Address - Street 2:DIV IM BONE MARROW TRANSPLANT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1003
Practice Address - Country:US
Practice Address - Phone:314-454-8304
Practice Address - Fax:314-454-5902
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2020041309207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200092603Medicaid