Provider Demographics
NPI:1396043758
Name:BOLDUAN, JERRY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
Last Name:BOLDUAN
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 1:10450 CHERRY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-9028
Mailing Address - Country:US
Mailing Address - Phone:707-823-5583
Mailing Address - Fax:
Practice Address - Street 1:10450 CHERRY RIDGE RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-9028
Practice Address - Country:US
Practice Address - Phone:707-823-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG032312208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice