Provider Demographics
NPI:1710946561
Name:BOLES, KEITH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:BOLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:500 SOUTH JOHNSON DRIVE
Practice Address - Street 2:
Practice Address - City:MCGREGOR
Practice Address - State:TX
Practice Address - Zip Code:76657
Practice Address - Country:US
Practice Address - Phone:254-313-5200
Practice Address - Fax:254-313-4531
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B5536OtherBLUE SHIELD
TX1119000-10OtherCSHCN
TX1119000-07Medicaid
TX080176902OtherRR/MEDICARE
TX8273N4Medicare ID - Type Unspecified
TX080176902OtherRR/MEDICARE