Provider Demographics
NPI:1306846076
Name:BOLTON SMITH, JODY ALLISON (MD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:ALLISON
Last Name:BOLTON SMITH
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:PO BOX 7366
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7366
Mailing Address - Country:US
Mailing Address - Phone:320-257-5595
Mailing Address - Fax:320-257-5596
Practice Address - Street 1:1990 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-257-5595
Practice Address - Fax:320-257-5596
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN465272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2141654OtherARAZ/ AMERICA'S PPO
MN16-03053OtherMEDICA
MN284L1BOOtherBLUE CROSS BLUE SHIELD
MN411772562OtherGREATWEST HEALTHCARE
MN965251040913OtherPREFERRED ONE
MN131470C561OtherUCARE OF MINNESOTA
MN411772562OtherTRICARE
MN492485100Medicaid
MNHP44741OtherHEALTH PARTNERS
MN300003456Medicare ID - Type Unspecified
MN492485100Medicaid