Provider Demographics
NPI:1558339374
Name:BOLER, DOUGLAS E (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:E
Last Name:BOLER
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 1:4730 N HABANA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7148
Mailing Address - Country:US
Mailing Address - Phone:813-549-2134
Mailing Address - Fax:813-864-4436
Practice Address - Street 1:202 S MADISON ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5479
Practice Address - Country:US
Practice Address - Phone:229-226-1035
Practice Address - Fax:229-226-3378
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91494207L00000X, 207LP2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL161ZMedicare PIN
FLPENDINGMedicare PIN
I27733Medicare UPIN