Provider Demographics
NPI:1558376608
Name:BOLTON, KIM P (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:P
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3166
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:512-231-5203
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ9980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118464004Medicaid
TX080146949Medicaid
TX118464003Medicaid
TX080146949Medicaid
TX8K2090Medicare PIN