Provider Demographics
NPI:1497081020
Name:BOLDT, THOMAS
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:BOLDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 PACIFIC ST APT 206
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2477
Mailing Address - Country:US
Mailing Address - Phone:310-980-2207
Mailing Address - Fax:310-917-2204
Practice Address - Street 1:501 PACIFIC ST APT 206
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-2477
Practice Address - Country:US
Practice Address - Phone:310-980-2207
Practice Address - Fax:310-917-2204
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12305171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist