Provider Demographics
NPI:1225358369
Name:BOLANOS, RICHARD GERALD JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GERALD
Last Name:BOLANOS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICARDO
Other - Middle Name:G
Other - Last Name:BOLANOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4352 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2138
Mailing Address - Country:US
Mailing Address - Phone:314-531-5444
Mailing Address - Fax:314-531-0063
Practice Address - Street 1:4352 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2138
Practice Address - Country:US
Practice Address - Phone:314-531-5444
Practice Address - Fax:314-531-0063
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2010020453207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program