Provider Demographics
NPI:1790754000
Name:BOLDON, BILLY (DO)
Entity Type:Individual
Prefix:DR
First Name:BILLY
Middle Name:
Last Name:BOLDON
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:PO BOX 1410
Mailing Address - Street 2:ATTN CLINIC ADMINISTRATION
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1410
Mailing Address - Country:US
Mailing Address - Phone:662-459-1187
Mailing Address - Fax:662-459-1147
Practice Address - Street 1:1405 STRONG AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4035
Practice Address - Country:US
Practice Address - Phone:662-459-7030
Practice Address - Fax:662-459-1104
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12903208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113949Medicaid