Provider Demographics
NPI:1417969205
Name:BOLES, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:BOLES
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 1:227 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2969
Mailing Address - Country:US
Mailing Address - Phone:478-272-1304
Mailing Address - Fax:478-275-1375
Practice Address - Street 1:227 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2969
Practice Address - Country:US
Practice Address - Phone:478-272-1304
Practice Address - Fax:478-275-1375
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045731207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00797266BMedicaid
GA00797266BMedicaid
GAG61822Medicare UPIN