Provider Demographics
NPI:1356317747
Name:BOLES, SCOTT M (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:BOLES
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:PO BOX 23540
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-3540
Mailing Address - Country:US
Mailing Address - Phone:858-565-0950
Mailing Address - Fax:858-244-1100
Practice Address - Street 1:8745 AERO DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1774
Practice Address - Country:US
Practice Address - Phone:858-565-0950
Practice Address - Fax:858-244-1100
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG850632085B0100X, 2085R0202X, 2085U0001X, 2085N0700X, 2085N0904X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083812Medicaid
CAGR0083813Medicaid
CAGR0083816Medicaid
CAZZZ75341ZMedicaid
CAGR0083817Medicaid
CAGR0083811Medicaid
CAGR0083815Medicaid
CAGR0083810Medicaid
CAGR0083817Medicaid
CAGR0083812Medicaid
CAW529AMedicare PIN
CAHW529Medicare PIN
CAGR0083811Medicaid
CAZZZ75341ZMedicaid
CAHW529AMedicare PIN