Provider Demographics
NPI:1285642330
Name:BOLTON, DEWITT L (MD)
Entity Type:Individual
Prefix:
First Name:DEWITT
Middle Name:L
Last Name:BOLTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 SIXTH AVE
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3802
Mailing Address - Country:US
Mailing Address - Phone:601-798-7529
Mailing Address - Fax:601-798-7553
Practice Address - Street 1:906 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3802
Practice Address - Country:US
Practice Address - Phone:601-798-7529
Practice Address - Fax:601-798-7553
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011789Medicaid
MSB66096Medicare UPIN