Provider Demographics
NPI:1639581127
Name:BOLTON, ALEXANDER RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:RICHARD
Last Name:BOLTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-4846
Mailing Address - Fax:
Practice Address - Street 1:4600 MEMORIAL DR STE W1
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5359
Practice Address - Country:US
Practice Address - Phone:618-233-3066
Practice Address - Fax:618-233-3066
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.163598207RC0000X, 208M00000X
IL036163598207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADO-05182OtherIOWA MEDICAL LICENSE
IL036.163598OtherILLINOIS MEDICAL LICENSE