Provider Demographics
NPI:1417300732
Name:BOLOTOVA, OLENA (MD)
Entity Type:Individual
Prefix:
First Name:OLENA
Middle Name:
Last Name:BOLOTOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-2650
Mailing Address - Country:US
Mailing Address - Phone:631-644-5389
Mailing Address - Fax:
Practice Address - Street 1:260 PATCHOGUE YAPHANK RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4886
Practice Address - Country:US
Practice Address - Phone:631-654-8755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY311738207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400268620OtherMEDICARE