Provider Demographics
NPI:1598296923
Name:BOLTON, AUSTIN D
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:D
Last Name:BOLTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1714
Practice Address - Country:US
Practice Address - Phone:260-425-6030
Practice Address - Fax:260-425-6028
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4351207L00000X
KY04960207L00000X
IN02006973A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology