Provider Demographics
NPI:1366461766
Name:BOLANOS, JOSE HUMBERTO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:HUMBERTO
Last Name:BOLANOS
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 1:7217 GREEN SLOPE DR
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33541-1306
Mailing Address - Country:US
Mailing Address - Phone:813-782-5086
Mailing Address - Fax:813-715-4899
Practice Address - Street 1:7217 GREEN SLOPE DR
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33541-1306
Practice Address - Country:US
Practice Address - Phone:813-782-5086
Practice Address - Fax:813-715-4899
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45625208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD50530Medicare UPIN