Provider Demographics
NPI:1275653032
Name:BOLTON, ANTHONY (PHD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BOLTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8750
Mailing Address - Country:US
Mailing Address - Phone:631-331-4437
Mailing Address - Fax:631-331-4459
Practice Address - Street 1:464 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2814
Practice Address - Country:US
Practice Address - Phone:631-331-4377
Practice Address - Fax:631-331-4459
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01136782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV0B341Medicare ID - Type UnspecifiedMEDICARE ID#-SNOPJ
NYR50489Medicare UPIN