Provider Demographics
NPI:1437159217
Name:BOLDRY, THOMAS CRAIG (DPM)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:CRAIG
Last Name:BOLDRY
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 1:550 RUSH CREEK PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-9608
Mailing Address - Country:US
Mailing Address - Phone:816-455-1155
Mailing Address - Fax:816-455-1161
Practice Address - Street 1:550 RUSH CREEK PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9608
Practice Address - Country:US
Practice Address - Phone:816-455-1155
Practice Address - Fax:816-455-1161
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000575213E00000X
KS12-00227213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO302817903Medicaid
KS006783Medicare ID - Type Unspecified
MO8330580Medicare ID - Type Unspecified
MO302817903Medicaid