Provider Demographics
NPI:1477578698
Name:BOLIVAR, ALVARO (MD)
Entity Type:Individual
Prefix:
First Name:ALVARO
Middle Name:
Last Name:BOLIVAR
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 1:598 N F ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3110
Mailing Address - Country:US
Mailing Address - Phone:909-888-8152
Mailing Address - Fax:909-884-7530
Practice Address - Street 1:598 N F ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3110
Practice Address - Country:US
Practice Address - Phone:909-888-8152
Practice Address - Fax:909-884-7530
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38312208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383120Medicaid
CA00A383120Medicaid
CA00A383120Medicare ID - Type Unspecified