Provider Demographics
NPI:1225471873
Name:BOLDT, IRINA EUGENIEVNA (MD)
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:EUGENIEVNA
Last Name:BOLDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 W 8TH ST # FC-12
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-244-3903
Mailing Address - Fax:
Practice Address - Street 1:12620 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7131
Practice Address - Country:US
Practice Address - Phone:904-633-0585
Practice Address - Fax:904-633-0586
Is Sole Proprietor?:No
Enumeration Date:2013-04-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135983207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine