Provider Demographics
NPI:1518055441
Name:BOLTON, JOE RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:RANDOLPH
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 1:1377 E HERNDON AVE
Mailing Address - Street 2:#104
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3022
Mailing Address - Country:US
Mailing Address - Phone:559-450-7455
Mailing Address - Fax:559-450-7473
Practice Address - Street 1:1377 E HERNDON AVE
Practice Address - Street 2:#104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3022
Practice Address - Country:US
Practice Address - Phone:559-450-7455
Practice Address - Fax:559-450-7473
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3436208G00000X
CAG88027208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXG33601Medicare UPIN
TX611356Medicare ID - Type UnspecifiedMEDICARE