Provider Demographics
NPI:1568751717
Name:BOLEN, ROBERT DRAKE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DRAKE
Last Name:BOLEN
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 1:96 JONATHAN LUCAS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8900
Mailing Address - Country:US
Mailing Address - Phone:843-792-3220
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL UNIVERSITY OF SOUTH CAROLINA
Practice Address - Street 2:96 JONATHAN LUCAS STREET, CSB 301
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-6160
Practice Address - Country:US
Practice Address - Phone:843-792-3221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC380402084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program