Provider Demographics
NPI:1659767366
Name:BOLSTRIDGE, JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:BOLSTRIDGE
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:MCHE-QD (CREDS) BROOKE ARMY MEDICAL CENTER,
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:774-279-1134
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:BROOKE ARMY MEDICAL CENTER, MCHE-QD (CREDS)
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:774-279-1134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA102204710208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program