Provider Demographics
NPI:1346683547
Name:BOLTON, MARY GABRIELLE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:GABRIELLE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25707 SE 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-9176
Mailing Address - Country:US
Mailing Address - Phone:206-718-3868
Mailing Address - Fax:
Practice Address - Street 1:9730 3RD AVE NE STE 208
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2023
Practice Address - Country:US
Practice Address - Phone:206-522-5646
Practice Address - Fax:888-972-4693
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045876207RX0202X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD76148Medicare UPIN