Provider Demographics
NPI:1366456840
Name:BOLESTA, EDWARD STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:STEPHEN
Last Name:BOLESTA
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 1:3691 RUTGER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2515
Mailing Address - Country:US
Mailing Address - Phone:314-977-6828
Mailing Address - Fax:314-977-6777
Practice Address - Street 1:1402 S GRAND
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-577-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36579207ZP0101X, 207ZP0105X, 207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology