Provider Demographics
NPI:1407171390
Name:JOLLEY, BRYCE D (DPM)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:D
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79405 HIGHWAY 111
Mailing Address - Street 2:STE 9-401
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-8300
Mailing Address - Country:US
Mailing Address - Phone:760-771-8260
Mailing Address - Fax:
Practice Address - Street 1:47647 CALEO BAY DR
Practice Address - Street 2:STE 110
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8857
Practice Address - Country:US
Practice Address - Phone:760-771-8260
Practice Address - Fax:760-564-1418
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000875213E00000X
CAE5582213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist