Provider Demographics
NPI:1326105495
Name:BOLDT, BERT BOVARD II (BS PT)
Entity Type:Individual
Prefix:MR
First Name:BERT
Middle Name:BOVARD
Last Name:BOLDT
Suffix:II
Gender:M
Credentials:BS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 SALEM CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2810
Mailing Address - Country:US
Mailing Address - Phone:850-877-8177
Mailing Address - Fax:850-942-0128
Practice Address - Street 1:132 SALEM CT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2810
Practice Address - Country:US
Practice Address - Phone:850-877-8177
Practice Address - Fax:850-942-0128
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000829OtherPHYSICAL THERAPY LICENSE