Provider Demographics
NPI:1629098918
Name:BOLDEN, KELLE DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:DANIELLE
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLE
Other - Middle Name:BOLDEN
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:11 ATRIUM RIDGE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6438
Practice Address - Country:US
Practice Address - Phone:803-699-9992
Practice Address - Fax:803-865-7429
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29209207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC292098Medicaid
SCAA41435730Medicare PIN
SCAA4143F935Medicare UPIN