Provider Demographics
NPI:1487635462
Name:BOLTON, EDGAR B JR (DO)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:B
Last Name:BOLTON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 SE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1420
Mailing Address - Country:US
Mailing Address - Phone:954-445-1754
Mailing Address - Fax:954-766-8199
Practice Address - Street 1:1900 N UNIVERSITY DR
Practice Address - Street 2:SUITE 107
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3618
Practice Address - Country:US
Practice Address - Phone:954-441-1616
Practice Address - Fax:954-766-8199
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS2458207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037708200Medicaid
FLHF850AOtherMEDICARE PTAN
81981Medicare ID - Type Unspecified
FL037708200Medicaid