Provider Demographics
NPI:1386643831
Name:BOLAN, ROBERT KEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KEY
Last Name:BOLAN
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 1:1625 SCHRADER BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:323-993-7500
Mailing Address - Fax:323-308-4015
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-993-7500
Practice Address - Fax:323-308-4015
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39301174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG39301OtherSTATE LICENSE #
CA00G393010Medicaid
CAA47777Medicare UPIN
CA00G393010Medicaid