Provider Demographics
NPI:1629023692
Name:BOLTAX, JONATHAN PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PETER
Last Name:BOLTAX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7305
Mailing Address - Fax:307-739-4960
Practice Address - Street 1:555 E BROADWAY AVE STE 220
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-7305
Practice Address - Fax:307-739-4960
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9935A207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121002500Medicaid
UT942854057043Medicaid
UT000063076Medicare PIN