Provider Demographics
NPI:1467431080
Name:BOLICK, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:BOLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:858 S AUTO MALL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2983
Mailing Address - Country:US
Mailing Address - Phone:801-899-3828
Mailing Address - Fax:801-855-7548
Practice Address - Street 1:858 S AUTO MALL DR STE 102
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2983
Practice Address - Country:US
Practice Address - Phone:801-899-3828
Practice Address - Fax:801-855-7548
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33101207ZC0500X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ805003300Medicaid