Provider Demographics
NPI:1346242005
Name:BOLIVAR, DAVID ALFONSO (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALFONSO
Last Name:BOLIVAR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:292 POSADA LN
Mailing Address - Street 2:STE C
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-4054
Mailing Address - Country:US
Mailing Address - Phone:805-434-3133
Mailing Address - Fax:805-434-3850
Practice Address - Street 1:292 POSADA LN
Practice Address - Street 2:STE C
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4054
Practice Address - Country:US
Practice Address - Phone:805-434-3133
Practice Address - Fax:805-434-3850
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA68461208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A684610Medicaid
H66761Medicare UPIN
CAWA68461BMedicare PIN
CA00A684610Medicaid