Provider Demographics
NPI:1487864708
Name:BOLTON, MICHAEL TODD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:BOLTON
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 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-6834
Mailing Address - Fax:225-765-1202
Practice Address - Street 1:8200 CONSTANTIN BLVD FL 4
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3481
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-765-1202
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.2008702080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1071871Medicaid
MS04953094Medicaid
LA4N037DX80Medicare PIN