Provider Demographics
NPI:1568727238
Name:BOLALIN, GEROME VALLADOLID (MD)
Entity Type:Individual
Prefix:DR
First Name:GEROME
Middle Name:VALLADOLID
Last Name:BOLALIN
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 1:1717 S J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4933
Mailing Address - Country:US
Mailing Address - Phone:253-426-6341
Mailing Address - Fax:253-398-5687
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6341
Practice Address - Fax:253-398-5687
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074664A207R00000X
WAMD60819263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201305950Medicaid
000000976632OtherANTHEM (REID PHYSICIAN ASSOCIATES, INC.)
OH0121786Medicaid
WA2113646Medicaid